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 because urine protein of 3+ is a sign of preeclampsia, which is a complication of pregnancy that involves high blood pressure and damage to the kidneys or other organs¹². Preeclampsia can cause serious problems for both the mother and the baby, such as fetal growth restriction, placental abruption, preterm birth, eclampsia, and HELLP syndrome¹². The nurse should report this finding to the provider and monitor the client's blood pressure, reflexes, and fetal well-being. The client may need medication to lower blood pressure and prevent seizures, such as magnesium sulfate or antihypertensives¹².

The other options are not correct because:
a) Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia. Deep tendon reflexes are graded from 0 to 4+, with 2+ being the average response⁶. Increased reflexes (3+ or 4+) may suggest hyperreflexia, which can be a sign of preeclampsia or magnesium toxicity¹⁶.
b) Blood glucose of 110 mg/dL is normal and does not indicate preeclampsia. Blood glucose is the amount of sugar in the blood, and it can vary depending on the time of day, diet, and activity level. The normal range for blood glucose is 70 to 130 mg/dL before meals and less than 180 mg/dL after meals⁷. High blood glucose (hyperglycemia) can be a sign of gestational diabetes, which is a type of diabetes that develops during pregnancy⁷.
d) Hemoglobin of 13 g/dL is normal and does not indicate preeclampsia. Hemoglobin is the protein in red blood cells that carries oxygen throughout the body. The normal range for hemoglobin is 12 to 16 g/dL for women and 14 to 18 g/dL for men⁷. Low hemoglobin (anemia) can be a sign of iron deficiency, bleeding, or infection⁷.

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.