The Prescription for the Patient's IV Infusion Reads, "100 ML/hr

The prescription for the patient's IV infusion reads, "100 mL/hr." The nurse observes that the patient's IV line infused 125 mL in addition to the ordered volume after 2 hours.Which is the most important intervention for the nurse to implement?

A) Compare weight to baseline data.
B) Replace the infusion pump batteries.
C) Assess the patient for respiratory distress.
D) Reduce the infusion rate below 75 mL/hr.