After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?
Explanation & Rationale
A. Note the presence of an auscultatory gap: An auscultatory gap is a period of silence that can occur between the systolic and diastolic readings, but the presence of an initial Korotkoff sound after silence does not necessarily indicate this without further context. B. Continue with the blood pressure assessment: Hearing the first Korotkoff sound marks the systolic pressure. The nurse should continue listening until the sounds disappear to determine the diastolic pressure and complete the accurate blood pressure measurement. C. Reposition the stethoscope over the brachial artery: Repositioning is only necessary if the nurse cannot hear any sounds; since the Korotkoff sound has been heard, the placement is correct. D. Reinflate the cuff to a higher number: Re-inflation is not necessary once the first sound has been heard and the assessment is underway; doing so may cause discomfort and is not needed unless an error occurred in technique.