Which comfort measure should the nurse use to assist the laboring woman to relax?

A. The right arm: Measuring blood pressure in only one arm can miss important pressure discrepancies that occur with certain congenital heart defects, particularly those involving obstruction of systemic blood flow. Upper-extremity readings alone do not provide a complete hemodynamic picture.

B. The left arm: While the left arm may reflect systemic circulation, isolated measurement does not allow comparison between upper and lower extremities, which is essential for detecting defects such as coarctation of the aorta. A single-site reading limits diagnostic value.

C. All four extremities: Congenital heart defects, especially coarctation of the aorta, often cause higher blood pressure in the arms and lower pressure in the legs due to narrowing of the aorta distal to the subclavian arteries. Measuring all four extremities allows detection of pressure gradients that strongly suggest CHDs.

D. Both arms while the child is crying: Crying can falsely elevate blood pressure due to sympathetic stimulation and does not provide reliable or comparative data. Additionally, measuring only the arms fails to assess lower-extremity perfusion differences critical in CHD evaluation.

A. Administer analgesics: Pain control is essential after a tonsillectomy to promote oral intake and comfort. Analgesics reduce throat discomfort and help the child maintain hydration and nutrition, but they do not directly prevent life-threatening complications such as postoperative hemorrhage.

B. Encourage the child to drink liquids: Hydration supports mucosal healing and prevents dehydration, which is a common postoperative concern. However, while encouraging fluid intake is important, it does not directly address the risk of sudden, severe bleeding that can occur after tonsillectomy.

C. Inspect the throat for bleeding: Post-tonsillectomy hemorrhage is the most serious complication, especially within the first 24 hours and around 5–10 days post-surgery when the scabs begin to slough. Careful observation for signs of active bleeding, such as frequent swallowing, vomiting blood, or fresh blood in the mouth, is critical to detect hemorrhage early.

D. Apply an ice collar: Ice collars can reduce local swelling and provide comfort by constricting blood vessels, helping with pain control. Although beneficial, this intervention does not address the immediate danger posed by postoperative bleeding and is secondary to monitoring for hemorrhage.