# 一位患有嚴重子癇前症的個案開始出現全身性癲癇發作。請將護理師的行動依優先順序排列。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395537&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位患有嚴重子癇前症的個案開始出現全身性癲癇發作。請將護理師的行動依優先順序排列。

將個案翻身至側臥姿勢，保護頭部，並移除附近危險物品，不限制其活動。

給予醫囑開立的 Magnesium sulfate 負荷劑量，並監測呼吸、反射和尿量。

留在個案身邊，立即呼叫求援，並記錄癲癇發作開始時間。

維持呼吸道通暢，視需要給予氧氣，並備妥抽吸設備，不強行將物品置入口中。

穩定後，重新評估母體血壓和神經學狀態，評估胎兒狀況，並記錄事件與處置反應。

## 解析

留在身邊並呼叫求援，採側臥姿勢並預防受傷，然後支持呼吸道與氧合。給予醫囑開立的 Magnesium sulfate 以控制並預防子癇症癲癇復發。母體重新評估先於胎兒狀況的判讀與穩定後的記錄。

## 深入解析

正確順序
留在身邊並呼叫 → 側臥保護 → 呼吸道與氧氣 → Magnesium sulfate → 母體與胎兒重新評估。

為何此為正確
在癲癇發作期間，護理師預防跌倒和誤吸，不限制個案活動或將任何物品置入口中。隨著癲癇發作結束，支持呼吸道與氧合。Magnesium sulfate 是子癇症建議使用的抗癲癇藥物，需要監測呼吸抑制、反射減弱和腎臟清除率受損。

NCLEX 決策規則
先穩定懷孕個案。胎兒氧合取決於母體呼吸道、通氣和循環。參考資料
1WHO recommendations for pre-eclampsia and eclampsia

## 臨床情境

子癇症緊急情況
個案在裝有加墊床欄的產房內。依常規醫囑開立 Magnesium sulfate，但尚未開始給予。胎兒監視器保持連接。

## 重要概念

- **子癇症** — 與妊娠高血壓疾病相關的新發作癲癇，且無其他更可能的原因。
- **Magnesium Sulfate** — 用於治療和預防子癇症癲癇復發的建議抗癲癇藥物。
- **側臥姿勢** — 一種有助於呼吸道引流並降低吸入性風險的姿勢。

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