Practice Quiz

CCNS Certified Clinical Nurse Specialist

Category - Neonatal

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A preterm neonate, born at thirty-one weeks gestation, is receiving an intravenous electrolyte solution at a rate of 20-22 mL/hr via an umbilical arterial line. At the hourly intake measurement, the nurse determines that 45 mL have infused in the past hour. The most appropriate initial nursing action is to:
  1. Check the physician’s order
  2. Set the infusion rate to 10-11 mL/hr on the next two hours
  3. Take the vital signs
  4. Compare the intake with the output
Explanation
Answer - C - The most appropriate initial nursing action is to take the vital signs. It is a priority to assess circulatory overload; changes in the vital signs would indicate a problem that must be addressed quickly.
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