— 降低風險 · HARD · MCQ —
一位患有高血壓且因妊娠毒血症接受硫酸鎂靜脈輸注的孕婦，下列哪項評估結果最需要立即報告醫師？
A nurse is assessing a client with a history of hypertension who is receiving an IV infusion of magnesium sulfate for preeclampsia. Which finding is the most critical to report to the provider?
- ARespiratory rate of 10 breaths/min✓ 正解呼吸頻率為 10 次/分鐘
- BClient report of a warm, flushed sensation病人報告有溫暖、潮紅的感覺
- CPresence of 1+ pitting edema in the lower extremities下肢出現 1+ 凹陷性水腫
- DDeep tendon reflexes of 2+深層肌腱反射為 2+
— Explanation · 中文詳解 —
硫酸鎂中毒跡象包括呼吸抑制、肌腱反射消失與尿量減少。呼吸頻率降至 12 次/分以下是嚴重的毒性指標，必須立即停止輸注並給予鈣劑解毒。B 為常見水腫；C 為輸注常見副反應；D 為正常反應，皆不需緊急停藥。
Respiratory depression is a critical sign of magnesium sulfate toxicity and requires immediate intervention, such as stopping the infusion and administering calcium gluconate. While flushing and mild edema are expected side effects, and 2+ reflexes are normal, a respiratory rate below 12 breaths per minute indicates severe toxicity that threatens the client's airway.
✦ 台美臨床差異
美台產科對於硫酸鎂監測標準一致，皆將呼吸率與膝跳反射列為評估核心。