A nurse is preparing to assess a 9-month-old infant admitted to the hospital for further evaluation of an atrial septal defect (ASD). Which should the nurse do first for the cardiac assessment?
a. Percussion
b. Palpation
c. Auscultation
d. History and inspection
D
The assessment should begin with the least threatening interventions—the history and inspection. Assessment progression includes inspection, auscultation, and palpation because each step includes more touching. Percussion of the chest is usually deferred. Palpation can be threatening to the child because it requires a significant amount of physical contact. For this reason it is not the initial step in a cardiac assessment. Auscultation requires touching the child and is not the initial step in a cardiac assessment.
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