護理師監測一位正因子癇前症接受硫酸鎂（Magnesium Sulfate）靜脈輸注的病人。下列哪項發現應立即通報醫師？
A nurse is monitoring a client receiving an intravenous infusion of magnesium sulfate for pre-eclampsia. Which finding should the nurse report to the healthcare provider immediately?
- ADeep tendon reflexes of 1+深腱反射為1+
- BUrine output of 40 mL/hour尿量為40 mL/小時
- CRespiratory rate of 10 breaths/minute✓ 正解呼吸速率為10次/分鐘
- DClient reports feeling warm and flushed病人主訴感覺溫暖且臉紅
硫酸鎂在產科用於預防子癇症發作，但其毒性風險高，監測重點在於神經肌肉與呼吸抑制。核心安全指標包括：呼吸速率（需 >12 次/分）、深腱反射（DTR, 需存在）、尿量（需 >30 mL/小時，因為鎂經腎臟排泄）。呼吸頻率下降至 10 次/分（選項 C）是呼吸抑制的早期徵象，預示著血鎂濃度已達到中毒水準，這可能導致心跳停止。DTR 1+（選項 A）雖然稍弱，但仍存在，若 DTR 消失（0）才是毒性指標。尿量 40 mL/hr 是正常的。感覺溫暖發紅（選項 D）是輸注初期的常見副作用，非通報急症。護理師必須具備「ABC」優先意識，呼吸抑制永遠是最高風險。
Magnesium sulfate is used in obstetrics for prevention of eclampsia, but it has a high risk of toxicity, and monitoring focuses on neuromuscular and respiratory depression. Core safety parameters include respiratory rate (must be >12 breaths/min), deep tendon reflexes (DTRs, must be present), and urine output (must be >30 mL/hr because magnesium is excreted by the kidneys). A respiratory rate dropping to 10 breaths/min (option C) is an early sign of respiratory depression and indicates that serum magnesium has reached toxic levels, potentially leading to cardiac arrest. A DTR of 1+ (option A) is slightly diminished but still present; only the absence of DTRs (0) is the toxicity indicator. Urine output of 40 mL/hr is normal. Feeling warm and flushed (option D) is a common side effect during the initial infusion and is not an emergency to report. The nurse must maintain ABC priority awareness — respiratory depression is always the greatest risk.
美國 NCLEX 考題中，硫酸鎂的毒性監測與拮抗劑（Calcium Gluconate）是合併考點。台灣臨床作業中，護理師會非常嚴密地記錄 I/O 與 DTR，但對於「何時該立即停藥」的自主決定權在美國護理指引中更為強調。