— 降低風險 · MEDIUM · MCQ —
一位子癇前症病人正在接受硫酸鎂持續滴注，哪項評估結果需要護理師立即採取行動？
A client is receiving a continuous infusion of magnesium sulfate for preeclampsia. Which assessment finding requires immediate nursing action?
- ARespiratory rate is 14 breaths/min呼吸頻率為每分鐘 14 次
- BBlood pressure is 145/90 mmHg血壓為 145/90 mmHg
- CUrinary output is 40 mL/hr尿量為 40 mL/hr
- DDeep tendon reflexes are 1+✓ 正解深層肌腱反射為 1+
— Explanation · 中文詳解 —
硫酸鎂中毒的早期跡象是深部腱反射（DTR）減弱或消失。當反射由正常的 2+ 降至 1+，意味著藥物濃度接近中毒邊緣，應考慮減量或暫停。呼吸頻率 14 次/分正常，尿量 >30 mL/hr 也屬正常範圍，血壓數值則需視整體臨床表現調整。
An early sign of magnesium sulfate toxicity is diminished or absent deep tendon reflexes (DTRs). When reflexes decrease from a normal 2+ to 1+, the drug level is approaching toxicity and a dose reduction or pause should be considered. A respiratory rate of 14 breaths/min is normal, urine output >30 mL/hr is also within the normal range, and the blood pressure value must be evaluated in the overall clinical context.
✦ 台美臨床差異
美國護理師常執行床邊毒性評估；台灣在婦產科領域常見由產房護理師嚴密監測並隨時向產科醫師回報。