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?

Sore nipples are a common problem for breastfeeding mothers, especially in the first few days or weeks after delivery. They can cause pain, discomfort, and frustration, and may interfere with breastfeeding success and satisfaction. The most common cause of sore nipples is poor latch, which means that the newborn does not attach to the breast correctly and does not suckle effectively. Poor latch can result from various factors, such as improper positioning, tongue-tie, inverted or flat nipples, engorgement, or thrush.

The nurse should assess the newborn's latch while breastfeeding to identify and correct any problems that may cause sore nipples. The nurse should observe the following signs of a good latch:
- The newborn's mouth is wide open and covers most of the areola (the dark area around the nipple).
- The newborn's chin and nose touch the breast, and the cheeks are rounded and not dimpled.

- The newborn's tongue is visible under the lower lip and curls around the breast.
- The newborn's lips are flanged outwards and not tucked inwards.
- The newborn's jaw moves rhythmically and smoothly, and swallowing sounds are audible.
- The mother feels a gentle tugging sensation on the nipple, but no pain or pinching.

The nurse should also teach the mother how to achieve a good latch by using different positions, supporting the breast with her hand, tickling the newborn's lower lip with her nipple, and bringing the newborn to the breast when their mouth is wide open. The nurse should also encourage the mother to seek help from a lactation consultant or a peer support group if she has persistent or severe nipple pain.

a) Instructing the client to wait 4 hours between daytime feedings is not an appropriate action for the nurse to take. This may reduce nipple soreness temporarily, but it can also cause breast engorgement, milk supply reduction, mastitis, or poor weight gain in the newborn. The nurse should advise the client to feed the newborn on demand, usually every 1.5 to 3 hours during the day and every 3 to 4 hours at night.
b) Offering supplemental formula between the newborn's feedings is not an appropriate action for the nurse to take. This may interfere with breastfeeding initiation and establishment, as it can reduce the mother's milk supply, confuse the newborn's sucking pattern, increase the risk of nipple preference or rejection, and expose the newborn to potential allergens or infections. The nurse should support exclusive breastfeeding for the first six months of life, unless there is a medical indication for supplementation.
c) Having the client limit the length of breastfeeding to 5 minutes per breast is not an appropriate action for the nurse to take. This may not be enough time for the newborn to get enough milk, especially the hindmilk that is richer in fat and calories. It may also prevent proper drainage of the breast and lead to engorgement or mastitis. The nurse should advise the client to let the newborn feed until they are satisfied and release the breast on their own, which may take 10 to 20 minutes per breast on average.

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.