When assessing a child for possible congenital heart defects (CHDs), where should the nurse measure blood pressure?
a. The right arm c. All four extremities
b. The left arm d. Both arms while the child is crying
ANS: C
When a CHD is suspected, the blood pressure should be measured in all four extremities while the child is quiet. Discrepancies between upper and lower extremities may indicate cardiac disease. Blood pressure measurements for upper and lower extremities are compared during an assessment for CHDs. Blood pressure measurements when the child is crying are likely to be elevated; thus the readings will be inaccurate.
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