護理師正在監測一位因子癇前症接受硫酸鎂（magnesium sulfate）靜脈輸注的病患。下列哪項發現需要立即處理？
The nurse is monitoring a client receiving an intravenous infusion of magnesium sulfate for preeclampsia. Which finding requires immediate intervention?
- ADeep tendon reflexes 1+深腱反射 1+
- BRespirations of 10 breaths per minute✓ 正解呼吸速率為每分鐘 10 次
- CUrinary output of 40 mL per hour每小時尿液排出量 40 mL
- DBlood pressure of 140/90 mmHg血壓 140/90 mmHg
硫酸鎂的安全管理核心在於預防高鎂血症導致的呼吸抑制與心臟停搏。為何 B 正確：呼吸速率下降（<12 次/分）是鎂離子中毒的危險紅旗，代表神經肌肉傳導受阻已擴及呼吸肌，必須立即停藥並考慮給予解毒劑。為何其他選項錯：A（血壓）仍屬子癇前症的預期範圍。B（深腱反射 1+）雖然偏低（正常 2+），但在輸注期間常見，應持續觀察，但呼吸抑制（B）更具生命威脅。D（尿量）每小時 40mL 高於最低標準 30mL。臨床思路：評估順序應為呼吸 > 深腱反射 > 尿量，因為呼吸衰竭是最直接的致死原因。
Safe management of magnesium sulfate centers on preventing respiratory depression and cardiac arrest from hypermagnesemia. Why B is correct: a decrease in respiratory rate (<12/min) is a red flag of magnesium toxicity, indicating that impaired neuromuscular conduction has extended to the respiratory muscles; the infusion must be stopped immediately and an antidote considered. Why the other options are incorrect: A (blood pressure) remains within the expected range for preeclampsia; B (1+ deep tendon reflexes), although decreased (normal is 2+), is commonly seen during infusion and warrants continued observation, while respiratory depression (B) is more immediately life-threatening; D (urine output) of 40 mL/hr exceeds the minimum threshold of 30 mL/hr. Clinical reasoning: the assessment order should be respirations > deep tendon reflexes > urine output, because respiratory failure is the most immediate cause of death.
美國產科病房對硫酸鎂的使用有極嚴格的 1-to-1 或 1-to-2 護理配比，且 Calcium Gluconate（解毒劑）必備於床邊；台灣多數醫院雖有規範，但解毒劑可能存放在急救車而非床邊，護理監測頻率依各院常規而異。