A nurse obtains a blood pressure reading on a 5-year-old client. While the client is in good health, has been cooperative, and appears to be calm, the reading is higher than normal for a child this age. Which of these actions should the nurse take?
a. Assess the need for a larger cuff.
b. Use a smaller cuff.
c. Recheck the blood pressure again at the end of the assessment.
d. Report this finding to the health care provider immediately.
A
The size of the cuff is determined by the size of the child's arm or leg. The bladder of the cuff is two-thirds of the width of the limb. If the bladder is too small, the pressure will be falsely high; if the bladder is too large, it will be falsely low.
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