While assessing a school-age child, the nurse notices a regular–irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. Which nursing action is appropriate based on these data?
1. Record the finding as normal.
2. Notify the healthcare provider.
3. Schedule an electrocardiogram (ECG) immediately.
4. Ask the mother if a murmur has been detected before.
1
Explanation:
1. This is sinus arrhythmia and is a normal finding in children but not in adults.
2. This is a normal finding. It should be recorded, not reported.
3. Nurses do not order tests, including ECGs.
4. There is no evidence of a murmur in the assessment data provided. This is a normal finding.
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