A nurse in the pediatric unit is preparing to take the blood pressure readings of several clients. When assessing blood pressure in a child:
Knowledge of normal mean is important: newborn, 65/41 mm Hg; 1 month to 2 years, 95/58 mm Hg; and 2 to 5 years, 101/57 mm Hg.
Cuff size is the most important variable and should be measured using limb length.
The child is considered normotensive if the BP is below the 95th percentile.
Check upper- and lower-extremity BP to look for abnormalities such as aortic stenosis, which causes lower-extremity BP to be higher than upper-extremity BP.
The Correct Answer is A
Effective pediatric assessment includes not only age-appropriate interaction but also a solid understanding of developmental physiology. Therapeutic communication complements accurate assessment by helping nurses explain procedures and results in ways appropriate to the child’s age and developmental stage.
Rationale for correct answer:
A. Accurate interpretation of BP in pediatric patients requires an understanding of age-specific norms. Blood pressure gradually increases with age, so a reading of 95/58 mm Hg may be normal for a toddler but hypotensive for a school-age child. Using correct reference values ensures appropriate identification of hypotension or hypertension.
Rationale for incorrect answers:
B. While cuff size is crucial, it should be based on limb circumference, not length. The cuff bladder width should be approximately 40% of the arm circumference, and the length should cover 80–100% of the arm. Using the wrong size can yield inaccurate readings.
C. A child is normotensive if their BP is below the 90th percentile for age, sex, and height. Readings between the 90th and 95th percentiles are considered prehypertensive, while readings above the 95th percentile suggest hypertension.
D. In conditions like coarctation of the aorta, upper-extremity BP is higher than lower-extremity BP. A lower BP in the legs compared to the arms is a classic sign of this condition, not the reverse.
Take home points
- Know age-specific BP norms to detect abnormalities in pediatric clients.
- Use the correct cuff size, measured by arm circumference, for accurate readings.
- Interpret BP percentiles properly: Normal is below the 90th percentile.
- Compare upper and lower extremity BPs in suspected cardiac conditions like coarctation of the aorta, not aortic stenosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Effective pediatric assessmentincludes not only age-appropriate interaction but also a solid understanding of developmental physiology. Therapeutic communication complements accurate assessment by helping nurses explain procedures and results in ways appropriate to the child’s age and developmental stage.
Rationale for correct answer:
A. Accurate interpretation of BPin pediatric patients requires an understanding of age-specific norms. Blood pressure gradually increases with age, so a reading of 95/58 mm Hg may be normal for a toddler but hypotensive for a school-age child. Using correct reference values ensures appropriate identification of hypotension or hypertension.
Rationale for incorrect answers:
B. While cuff size is crucial, it should be based on limb circumference, not length. The cuff bladder width should be approximately 40% of the arm circumference, and the length should cover 80–100% of the arm. Using the wrong size can yield inaccurate readings.
C. A child is normotensiveif their BP is below the 90th percentilefor age, sex, and height. Readings between the 90th and 95th percentiles are considered prehypertensive, while readings above the 95th percentile suggest hypertension.
D. In conditions like coarctation of the aorta, upper-extremity BP is higherthan lower-extremity BP. A lower BP in the legscompared to the arms is a classic sign of this condition, not the reverse.
Take home points
- Know age-specific BP norms to detect abnormalities in pediatric clients.
- Use the correct cuff size, measured by arm circumference, for accurate readings.
- Interpret BP percentiles properly: Normal is below the 90th percentile.
- Compare upper and lower extremity BPs in suspected cardiac conditions like coarctation of the aorta, not aortic stenosis.
Correct Answer is A
Explanation
Weight assessment in childrenis the process of measuring and interpreting a child’s body weight in relation to age, height, and sex to evaluate growth, nutritional status, and overall health. It’s a key part of pediatric care and helps identify undernutrition, overweight, or obesity early on.
Rationale for correct answer:
A.If a toddler can stand alone, a standing scaleprovides an accurate weight and is more comfortable for the child. At 22 months, many children have the stability to stand still briefly for weighing.
Rationale for incorrect answers:
B.Infant scalesare generally used for babies and younger toddlers who cannot stand unsupported; by this age and developmental stage, a standing scale is suitable.
C.While involving the mother in care decisionsis important, the method of weighing is based on developmental capability, not caregiver preference.
D.The “subtracting method”is less accurate and is typically used only when the child cannot stand and an infant scale is unavailable.
Take home points
- Choose the weighing method based on developmental ability, not strictly on age.
- Standing scales are appropriate for toddlers who can stand still without assistance.
- Accurate anthropometric measurements are key for growth monitoring and detecting developmental or nutritional concerns.
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