A student nurse records a systolic blood pressure of 106 mm Hg for a 4-year-old child. Which response by the registered nurse is best?
A.
Ask the student if this is a normal finding.
B.
Have the student repeat the blood pressure.
C.
Refer the family to a health-care provider.
D.
Tell the student to document the results.
ANS: C
This blood pressure is in the 95th percentile for age. For screening purposes, a blood pressure greater than 20 mm Hg above normal for the child's age is considered a red flag for hypertension, and the child should be referred to a health-care provider. The other options are all appropriate but are not as important as referring the child for further workup.
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