孕婦因妊娠毒血症接受硫酸鎂靜脈滴注，護理師評估發現呼吸每分鐘 10 次且膝反射消失。首要護理介入為何？
A client is receiving an IV infusion of magnesium sulfate for preeclampsia. The nurse assesses the client and finds a respiratory rate of 10 breaths per minute and absent patellar reflexes. What is the priority nursing intervention?
- AStop the magnesium sulfate infusion immediately✓ 正解立即停止硫酸鎂靜脈滴注
- BIncrease the IV flow rate增加靜脈滴注速率
- CAdminister calcium gluconate給予葡萄糖酸鈣
- DDocument the findings and continue infusion記錄發現並繼續滴注
硫酸鎂（Magnesium sulfate）廣泛用於子癲前症以預防癲癇發作。該藥具有抑制神經肌肉傳導的作用。呼吸頻率降低（<12 次/分）與膝反射消失（Patellar reflex absent）是硫酸鎂中毒的早期警訊。護理師的首要行動是立即停止輸液，以防止藥物進一步累積導致呼吸抑制與心跳停止，隨後準備鈣離子拮抗劑。
Magnesium sulfate is widely used in preeclampsia to prevent seizures. The drug inhibits neuromuscular transmission. A decreased respiratory rate (<12/min) and absent patellar reflexes are early warning signs of magnesium sulfate toxicity. The nurse's first action is to immediately stop the infusion to prevent further drug accumulation, which could cause respiratory depression and cardiac arrest, and then prepare the calcium antagonist.