護理師照顧一位因預防子癲前症而接受硫酸鎂輸注的病人。下列哪項評估結果需要立即處置？
A nurse is caring for a client receiving an infusion of magnesium sulfate for eclampsia prophylaxis. Which assessment finding requires immediate intervention?
- AUrine output of 40 mL/hour尿量為每小時40毫升
- BAbsent patellar deep tendon reflexes✓ 正解膝反射消失
- CSerum magnesium level of 6 mg/dL血清鎂濃度為6 mg/dL
- DRespiratory rate of 16 breaths/min呼吸頻率為每分鐘16次
硫酸鎂中毒的三大警訊為深層肌腱反射消失、呼吸變慢及尿量減少。其中反射消失通常是中毒的最早指標。若出現反射消失，應立即停止輸注並備妥鈣離子拮抗劑（如葡萄糖酸鈣）。呼吸 16 次/分屬正常，血鎂 6 mg/dL 在治療窗內（4-7 mg/dL），尿量 40 mL/hr 亦在標準範圍內。
The three major warning signs of magnesium sulfate toxicity are loss of deep tendon reflexes, slowed respirations, and decreased urine output, with loss of reflexes typically being the earliest indicator of toxicity. If reflexes are absent, the infusion must be stopped immediately and a calcium antagonist (e.g., calcium gluconate) must be prepared. A respiratory rate of 16 breaths/min is normal; a serum magnesium level of 6 mg/dL is within the therapeutic window (4-7 mg/dL); and urine output of 40 mL/hr is within the standard range.
產科護理中，硫酸鎂的安全監測皆為標準作業程序，但美國醫院對於藥物警訊的電腦化提示系統更為嚴密。