An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
A.
Document in the client’s record.
B.
Prepare the client for an echocardiogram.
C.
Notify the healthcare provider.
D.
Limit the client’s fluids.
The correct answer and Explanation is :
The correct answer is A. Document in the client’s record.
Explanation
An S3 heart sound, also known as a third heart sound or “physiologic S3,” can often be heard in pregnant women, especially in the third trimester. This sound is typically a low-pitched, soft sound heard after the second heart sound (S2) and is associated with rapid ventricular filling. It is considered a normal physiological finding in pregnant women due to the increased blood volume and the increased workload on the heart.
Reasoning:
- Normal Physiological Changes: During pregnancy, blood volume increases significantly, and the heart works harder to pump this additional volume. As a result, an S3 heart sound may develop, which is often benign and expected. This sound is usually not indicative of heart disease in this context but rather reflects the increased volume and hemodynamic changes occurring due to pregnancy.
- No Immediate Intervention Needed: An S3 heart sound alone in the absence of other symptoms such as dyspnea, edema, or significant changes in blood pressure is generally not a cause for concern. It does not typically require an echocardiogram, restriction of fluids, or immediate notification to the healthcare provider unless accompanied by other signs of heart failure or significant symptoms.
- Documentation: The primary action for the nurse is to document the presence of the S3 heart sound in the client’s record. This ensures that the finding is noted for future reference and helps in monitoring if any new symptoms or changes occur. Documentation also serves as a reference for the healthcare team in case the condition evolves or if the client exhibits other symptoms that might warrant further investigation.
In summary, documenting the finding is appropriate as it acknowledges the sound, while continuous monitoring and assessment are key in ensuring that the finding remains benign and does not indicate any underlying pathology.