A crying toddler has a blood pressure reading of 120/70 mm Hg. What action should the nurse take?

• A. Notify the healthcare provider of the measurement.
• B. Document the finding and recheck in 4 hours.
• C. Quiet the child and retake the blood pressure.
• D. Ask the parent if the child has a history of hypertension.

Answer: (C)

Accurate pediatric blood pressure depends on the child being calm and at rest. Crying or distress can transiently raise blood pressure through sympathetic activation, so a reading taken while the child is upset is not reliable. The best next step is to quiet the child and retake the measurement using proper technique (cuff size appropriate, arm supported at heart level, correct limb, and after the child has had a moment to settle). If the repeat reading remains elevated after the child is calm, then follow the facility’s protocol, such as notifying the provider. Simply notifying the provider now would be premature before confirming accuracy; delaying action for hours neglects a potentially important measurement; and asking about hypertension history doesn’t address the immediate need to obtain an accurate reading.