During a routine clinic visit, a nurse finds that a 5-year-old girl’s systolic blood pressure is above the 90th percentile. What should be the nurse’s subsequent action?

The correct answer is choice d. Measure the blood pressure twice more during the visit and calculate the average of the three readings. Choice A rationale: Referring the child to the healthcare provider and scheduling a blood pressure evaluation in two weeks is not the immediate next step. It is important to confirm the elevated blood pressure reading during the same visit before making any referrals. Choice B rationale: Performing a comprehensive assessment and avoiding repeated blood pressure measurements is not appropriate. Repeated measurements are necessary to confirm the initial finding of elevated blood pressure. Choice C rationale: Taking the child’s blood pressure three times and recording the highest reading is not the best practice. The highest reading might not be representative of the child’s true blood pressure. Choice D rationale: Measuring the blood pressure twice more during the visit and calculating the average of the three readings is the correct approach. This method helps to ensure that the blood pressure reading is accurate and not influenced by temporary factors such as anxiety or movement.