病人因妊娠毒血症接受硫酸鎂點滴注射,下列何者顯示可能有藥物副作用?
A client is receiving an IV infusion of magnesium sulfate for pre-eclampsia. Which assessment finding indicates a potential adverse effect?
- ATachypnea呼吸過速
- BHypoactive deep tendon reflexes✓ 正解深層肌腱反射減弱
- CIncreased urine output尿量增加
- DHypertension高血壓
硫酸鎂(Magnesium Sulfate)作為妊娠毒血症(Pre-eclampsia)治療藥物,主要用於預防癲癇發作。其治療窗窄,極易產生毒性反應。護理師需監測的毒性徵兆包括:深部肌腱反射(DTRs)消失、呼吸頻率小於 12 次/分、尿量減少(<30 mL/hr)。若出現反射消失,代表血鎂濃度已過高,須立即停止給藥並準備鈣離子拮抗劑。
Magnesium sulfate is used in pre-eclampsia primarily to prevent seizures. It has a narrow therapeutic window and easily produces toxicity. Signs of toxicity the nurse must monitor include: absent deep tendon reflexes (DTRs), respiratory rate less than 12 breaths/min, and decreased urine output (<30 mL/hr). If reflexes are absent, the serum magnesium level is too high; the nurse must immediately stop the infusion and prepare the calcium antagonist (calcium gluconate).