After auscultating a patient's heart sounds and measuring vital signs, the nurse determines that which of the following assessment findings needs additional assessment?

Question

1. split of S2
2. bounding, vigorous pulse
3. pulse pressure of 30 to 40 mm hg
4. apical pulse of 60 to 80

Answer 1

1

Rationale: The split of S2 indicates that one ventricle is emptying earlier or later than another and that contractility may, therefore, be diminished. This would indicate the need for further assessment and is the correct answer. Pulse pressure is defined as the difference between diastolic and systolic blood pressure. The pulse pressure reflects how much the heart is able to raise the pressure in the arterial system with each beat. Pulse pressure of 30 to 40 mm Hg does not indicate cause for concern because it is within the normal pulse pressure range. Apical pulse of 60 to 80 is within normal limits also. Increased contractility is recognized in a bounding, vigorous pulse and, therefore, not cause for alarm.