After realizing a neonate-size cuff was used for blood pressure measurements, what should the nurse do next for a 9-month-old with a possible head injury?

When a neonate-size cuff has been used for blood pressure measurements in a 9-month-old, it is crucial to reassess the blood pressure using the appropriate cuff size. The correct approach involves using both a neonate-size and a child-size cuff in this context to assess how the measurement varies with different cuff sizes. This is particularly important given that blood pressure readings can be significantly affected by cuff size, and inaccuracies could lead to mismanagement of a potential head injury.

Utilizing both cuff sizes allows the nurse to compare the readings and determine if the earlier measurement was considerably skewed due to the size of the cuff. By capturing this data, the healthcare team can make informed decisions and provide appropriate care based on accurate blood pressure readings, especially in a patient where head injuries can lead to changes in blood pressure.

Using only a child-size cuff for future measurements would not take into account how the neonate-size cuff influenced the previous readings, and simply documenting the earlier measurements without changes overlooks the need for accurate monitoring critical in managing head injuries. Waiting for the physician before taking any further measurements could delay necessary interventions, which is particularly critical in cases involving potential head trauma.