護理師正在監測一名因子癇前症接受靜脈注射硫酸鎂 (Magnesium Sulfate) 的病人。哪項評估結果應立即通報醫師？
A nurse is monitoring a client receiving intravenous magnesium sulfate for preeclampsia. Which assessment finding should the nurse report to the healthcare provider immediately?
- ADeep tendon reflexes 1+深腱反射 1+
- BBlood pressure of 148/92 mmHg血壓 148/92 mmHg
- CRespiratory rate of 14 breaths per minute呼吸頻率 14 次/分鐘
- DUrinary output of 20 mL/hr over the last 2 hours✓ 正解過去 2 小時的尿液輸出量為 20 mL/hr
硫酸鎂主要經由腎臟排泄。當尿量減少（低於 30 mL/hr）時，鎂離子會在體內快速蓄積，導致鎂中毒。鎂中毒會抑制中樞神經系統，導致深腱反射消失、呼吸抑制甚至心跳停止。尿量減少通常是鎂中毒的最早警訊，因為它代表排泄途徑受阻。雖然 1+ 反射（A）也偏低，但「尿量減少」是導致後續所有中毒症狀的根源，故為首要介入點。呼吸率 14 次/分（C）仍屬正常範圍（<12 次才需擔心）。血壓 148/92（B）對於子癇前症病人是預期中的，並非硫酸鎂毒性的表現。護理師應立即停止滴注並通報醫師，必要時準備解毒劑（Calcium Gluconate）。
Magnesium sulfate is excreted primarily by the kidneys. When urine output decreases (below 30 mL/hr), magnesium quickly accumulates in the body and causes toxicity. Magnesium toxicity suppresses the central nervous system, causing loss of deep tendon reflexes, respiratory depression, and even cardiac arrest. A decrease in urine output is often the earliest warning sign of magnesium toxicity because it reflects impaired excretion. Although 1+ reflexes (A) are also reduced, the decrease in urine output is the root cause of subsequent toxicity and is therefore the priority intervention point. A respiratory rate of 14/min (C) remains within the normal range (rates below 12/min would be concerning). A blood pressure of 148/92 (B) is expected in a client with preeclampsia and is not a manifestation of magnesium toxicity. The nurse should immediately stop the infusion and notify the provider, preparing the antidote (calcium gluconate) if necessary.
美國 NCLEX 考試中，對於硫酸鎂中毒的監測有一組經典數值：尿量 >30mL/hr, DTR 2+, RR >12。美國護理師被訓練在尿量不足時具有「護理自主權」先行減慢或暫停輸液。台灣實務中，護理師通常會先測量尿量與 DTR，若異常則立即通報醫師決定是否調整流速，對解毒劑（葡萄糖酸鈣）的備置要求兩地皆同。