A nurse is assessing a child with an unrepaired ventricular ...

[fox]

A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?
 
  a. S3
  b. S4
  c. Murmur
  d. Physiologic splitting

Question 2

The nurse must assess a child's capillary refill time. This can be accomplished by:
 
  a. inspecting the chest.
  b. auscultating the heart.
  c. palpating the apical pulse.
  d. palpating the skin to produce a slight blanching.

[Moriaki]

Answer to Question 1

ANS: C
Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. These are the sounds expected to be heard in a child with a ventricular septal defect because of the abnormal opening between the ventricles. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.

Answer to Question 2

ANS: D
Capillary refill time is assessed by pressing lightly on the skin to produce blanching, and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary refill time.