The nurse is caring for a patient with heart failure. While auscultating heart sounds of this patient, the nurse hears an extra heart sound immediately after the second heart sound (S2). How would the nurse document this?
A) A first heart sound (S1)
B) A third heart sound (S3)
C) A fourth heart sound (S4)
D) A murmur
Ans: B
Feedback: An S3 is heard following an S2, which commonly occurs in patients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
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