Ace the 2026 Pharmacology Maternity HESI – Evolve Your Skills and Conquer the Test!

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If a preterm infant receiving an intravenous electrolyte solution infuses 40 mL in place of the prescribed 20 mL/hr, what should the nurse's first intervention be?

Notify the healthcare provider

Check the medication order

Take the vital signs

In situations where an infant is receiving an intravenous electrolyte solution and there is a concern about an infusion rate that has exceeded the prescribed limit, the priority action for the nurse is to check the vital signs. This intervention is crucial as it helps assess the current status of the infant and identify any immediate effects of the increased fluid volume.

Preterm infants are particularly vulnerable and can quickly develop complications such as fluid overload or changes in their cardiovascular status. By taking vital signs, the nurse can monitor for signs of distress, changes in heart rate, blood pressure, or respiratory status that may result from the infusion of a larger volume of solution. This information will guide further actions and interventions.

While notifying the healthcare provider, checking the medication order, or reassessing the IV line are important steps to take later, they do not address the immediate safety and well-being of the infant as effectively as assessing vital signs does. Monitoring the infant's condition should always come first in any situation where their safety may be at risk.

Reassess the intravenous line

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