A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?

Rationale:

A) The diastolic value is recorded as the disappearance of Korotkoff sounds (K5), not the first sound (K1).

B) The cuff pressure should be released at a rate of 2-3 mm Hg/second, not 5 mm Hg/second.

C) Positioning the child's arm at the level of the heart ensures an accurate blood pressure measurement.

D) The cuff bladder size should be approximately 40% of the child's upper arm circumference, not 20%.

Rationale for A: If the child can describe what frightened them, this would be more consistent with nightmares. Nightmares often involve the ability to recall details of the bad dream, whereas sleep terrors are typically associated with no memory of the event.

Rationale for B: Children with sleep terrors generally do not fully awaken and can usually go back to sleep immediately. This is a key distinction between sleep terrors and nightmares, where the child remains distressed for some time and may be hesitant to fall back asleep.

Rationale for C: Becoming fully awake and in a panic is more characteristic of nightmares, where the child may wake up terrified and struggle to calm down, unlike sleep terrors where they do not fully awaken.

Rationale for D: A child with nightmares is often easily comforted by the presence of a parent. In contrast, children with sleep terrors are difficult to comfort because they are not fully awake and may not respond to soothing efforts.