A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which of the following clinical findings should the nurse instruct the client to report?

This is the finding that the nurse should report to the provider following this medication. Butorphanol is an opioid analgesic that can cause respiratory depression as a serious side effect¹. A normal respiratory rate for an adult is 12 to 20 breaths per minute². A respiratory rate of 10/min is below the normal range and could indicate inadequate ventilation and oxygenation. The nurse should monitor the client's oxygen saturation, administer oxygen if needed, and notify the provider of this finding.

The other options are not correct because they are not signs of adverse effects from butorphanol. Let me
explain why:
a) Urinary Output 1 20 mL in 2 hr

This is a normal urinary output for an adult. A normal urinary output is 0.5 to 1 mL/kg/hr³. Assuming an average weight of 70 kg, this would be 35 to 70 mL/hr, or 70 to 140 mL in 2 hr. Therefore, a urinary output of 120 mL in 2 hr is within the normal range and does not need to be reported.
c) Moderate fetal heart rate variability
This is a reassuring sign of fetal well-being. Fetal heart rate variability is the amount of fluctuation in the fetal heart rate from the baseline. Moderate variability is defined as a fluctuation of 6 to 25 beats per minute (bpm) and indicates that the fetus is responsive and has adequate oxygenation⁴. Moderate variability does not need to be reported.
d) Blood pressure 136/88 mm Hg
This is a slightly elevated blood pressure, but not a sign of an adverse effect from butorphanol. Butorphanol does not cause significant changes in blood pressure¹. A normal blood pressure for an adult is less than 120/80 mm Hg⁵. A blood pressure of 136/88 mm Hg is considered elevated, but not hypertensive. The nurse should monitor the client's blood pressure and check for other signs of preeclampsia, such as proteinuria, headache, or visual changes. However, this finding does not need to be reported immediately.

Umbilical cord prolapse is a medical emergency that occurs when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during labor but can occur any time after the rupture of membranes³.
Umbilical cord prolapse can cause fetal hypoxia (lack of oxygen), bradycardia (slow heart rate), acidosis (high acidity in the blood), and death if not treated promptly. The immediate goal of management is to relieve the pressure on the cord and restore blood flow to the baby. The definitive treatment is an emergency cesarean section to deliver the baby as soon as possible¹².
While waiting for the cesarean section, the nurse should take several steps to reduce the risk of fetal
compromise, such as:
- Call for help and notify the provider
- Place the client in a knee-chest, Trendelenburg, or modified Sims position to shift the fetal weight off the
cord
- Exert continuous upward pressure on the presenting part with a sterile gloved hand to lift it away from
the cord
- Administer oxygen to the client at 8 to 10 L/min via a nonrebreather mask
- Administer IV fluids to maintain hydration and blood pressure
- Administer tocolytics (medications that stop uterine contractions) as ordered to reduce cord compression
- Monitor fetal heart rate and uterine activity continuously
- Provide emotional support and reassurance to the client and family

Exerting continuous upward pressure on the presenting part is a critical action that the nurse should take to prevent further cord compression and improve fetal oxygenation. The nurse should insert a sterile gloved hand into the vagina and gently push up on the fetal head or buttocks until delivery. The nurse should not attempt to push the cord back into the uterus or manipulate it in any way, as this could cause more damage or infection¹².

The other options are not actions that the nurse should take:
- a) Place the client in a left-lateral position for 1 hr. after administration. This is not correct because this position does not relieve the pressure on the cord. The client should be placed in a knee-chest, Trendelenburg, or modified Sims position instead.
- b) Initiate oxytocin via continuous IV infusion. This is not correct because oxytocin stimulates uterine contractions, which can worsen cord compression and fetal distress. The nurse should administer tocolytics instead to stop contractions.
- d) Request that the provider insert an intrauterine pressure catheter. This is not correct because an intrauterine pressure catheter is used to measure uterine contractions, not cord prolapse. Inserting a catheter could also increase the risk of infection or injury.