A nurse is caring for a client in the second stage of labor.

The nurse observes retraction of the fetal head against the maternal perineum after the fetal head is birthed.

What potential condition could the client be experiencing, what parameters should the nurse monitor to assess the client’s progress, and what actions should the nurse take?

Choice D rationale
Changes in the cervix, including effacement (thinning) and dilation (opening), are reliable signs of true labor. During true labor, contractions cause the cervix to thin and open to prepare for the passage of the baby. This is in contrast to Braxton Hicks contractions, or “false labor,” which are irregular and do not result in changes to the cervix.
Choice A rationale
The position of the presenting part can provide information about the progress of labor and the likely need for interventions, but it is not a definitive sign of labor.
Choice B rationale
Membrane rupture, or “water breaking,” can occur before or during labor. However, not all women experience a noticeable rupture of membranes, and sometimes the fluid can leak slowly, making it less noticeable.
Choice C rationale
A regular contraction pattern can be a sign of labor, but contractions can also occur in patterns during false labor. Therefore, contraction pattern alone is not a definitive sign of labor.

Choice A rationale
Abdominal pain accompanied by minimal red vaginal bleeding is not a typical symptom of placenta previa. In placenta previa, the placenta covers all or part of the cervix, which can cause severe bleeding. However, this bleeding is typically not associated with abdominal pain.
Choice B rationale
Intermittent abdominal pain following the passage of bloody mucus is not a common symptom of placenta previa. This symptom is more commonly associated with labor or other conditions, but not specifically with placenta previa.
Choice C rationale
Increasing abdominal pain with a nonrelaxed uterus is not a typical symptom of placenta previa. This could be a sign of other complications such as uterine rupture or placental abruption, which are serious conditions that require immediate medical attention.
Choice D rationale
Painless red vaginal bleeding is indeed a symptom of placenta previa. This bleeding is usually bright red and can occur intermittently or continuously. It is most common in the third trimester of pregnancy.