A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

A. Apply the largest cuff available. Using a cuff that is too large can result in falsely low readings. Cuff size should match the client’s arm circumference to ensure accuracy, but simply switching to the largest cuff does not resolve difficulty in auscultation.
B. Deflate the cuff quickly. Rapid deflation can cause the nurse to miss the systolic and diastolic sounds, making it harder to obtain an accurate reading. The cuff should be deflated at a steady rate of 2–3 mmHg per second.
C. Use the palpatory method to determine blood pressure. When sounds are difficult to auscultate, the palpatory method is a reliable alternative. This involves palpating the radial pulse while inflating the cuff to estimate systolic pressure, which helps guide a more accurate auscultatory attempt.
D. Place the arm above the level of the client's heart. Elevating the arm above heart level can lower the pressure artificially, resulting in an inaccurate measurement. For correct results, the arm should be supported at heart level.

A. Administer packed RBCs. While blood transfusion may be urgently needed for hemorrhagic shock, it cannot be initiated until vascular access is established. It is important, but not the first step.
B. Obtain a specimen for ABG analysis. Arterial blood gases can provide valuable information about respiratory and metabolic status, but they are not the top priority in an unstable trauma patient.
C. Place a large-bore IV catheter in an upper extremity. Establishing IV access is the priority in trauma care, as it allows for rapid fluid resuscitation and medication administration. This intervention supports all subsequent emergency treatments.
D. Insert an indwelling urinary catheter. A catheter may be necessary for monitoring urine output as a sign of perfusion, but this is not the first action in a trauma situation where immediate stabilization is the priority.