A nurse is planning care for a client who is at 16 weeks of gestation and has hyperemesis gravidarum. Which of the following actions should the nurse anticipate taking?

A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.

A. Ask the provider to spell out the name of the medication. Asking the provider to spell out the name of the medication is important to ensure accuracy and prevent medication errors. This step helps clarify any potential confusion regarding similar-sounding medications or names, reducing the risk of administering the wrong drug.
B. Withhold the medication until the provider signs the prescription. Withholding the medication until the provider signs the prescription is not necessary. Telephone prescriptions are valid and can be administered after being documented appropriately, provided that the nurse follows institutional policies regarding the signing of prescriptions. This means that the nurse should not delay necessary medication administration based on awaiting a signature.
C. Record the date and time of the telephone prescription. Recording the date and time of the telephone prescription is essential for accurate medical documentation. This information is critical for maintaining an accurate medication administration record and for legal purposes, ensuring that there is a clear timeline of the prescription order.
D. Request that the provider confirm the read-back of the prescription. Requesting that the provider confirm the read-back of the prescription is a crucial step in ensuring the accuracy of the prescription. The read-back method helps confirm that the nurse understood the prescription correctly and prevents potential errors by allowing the provider to verify the information relayed.
E. Instruct another nurse to record the prescription in the medical record. Instructing another nurse to record the prescription in the medical record is not appropriate. The nurse who received the telephone prescription should document it to maintain accountability and ensure accurate record-keeping. This promotes responsible practice and avoids miscommunication regarding the prescription details.