# Heart sounds quizlet

## Korotkoff Sounds

Korotkoff sounds are generated when a blood pressure cuff changes the flow of blood through the artery. These sounds are heard through either a stethoscope or a doppler that is placed distal to the blood pressure cuff.

There are five distinct phases of Korotkoff sounds:

Phase 1: A sharp tapping.

This is the first sound heard as the cuff pressure is released. This sound provides the systolic pressure reading.

Phase 2: A swishing/whooshing sound.

Swishing sounds as the blood flows through blood vessels as the cuff is deflated.

Phase 3: A thump (softer than phase 1).

Intense thumping sounds that are softer than phase 1 as the blood flows through the artery but the cuff pressure is still inflated to occlude flow during diastole.

Phase 4: A softer, blowing, muffled sound that fades.

Softer and muffled sounds as the cuff pressure is released. The change from the thump of phase 3 to the muffled sound of phase 4 is known as the first diastolic reading.

Phase 5: Silence.

Silence that occurs when the cuff pressure is released enough to allow normal blood flow. This is known as the second diastolic reading.

Learn more about blood pressure here: https://www.ausmed.com.au/cpd/articles/how-to-take-blood-pressure.

Sours: https://www.ausmed.com

### Electrical Events

Cardiac contraction is initiated in the excitable cells of the sinoatrial (SA) node by both spontaneous depolarization and sympathetic activity.

### Learning Objectives

Describe the electrical events of the heart

### Key Takeaways

#### Key Points

• The sinoatrial (SA) and atrioventricular (AV) nodes make up the intrinsic conduction system of the heart by setting the rate at which the heart beats.
• The SA node generates action potentials spontaneously.
• The SA node fires at a normal rate of 60–100 beats per minute (bpm), and causes depolarization in atrial muscle tissue and subsequent atrial contraction.
• The AV node slows the impulses from the SA node, firing at a normal rate of 40-60 bpm, and causes depolarization of the ventricular muscle tissue and ventricular contraction.
• Sympathetic nervous stimulation increases the heart rate, while parasympathetic nervous stimulation decreases the heart rate.

#### Key Terms

• pacemaker: A structure that sets the rate at which the heart beats. Under normal conditions, the SA node serves this function for the heart.
• atrioventricular (AV) node: The bundle of conducting tissue that receives impulses from the SA node and delays them before stimulating depolarization in the muscles of the ventricles.

The heart’s activity is dependent on the electrical impulses from the sinoatrial (SA) node and atrioventricular (AV) node, which form the intrinsic conduction system of the heart. The SA and AV nodes act as a pacemaker for the heart, determining the rate at which it beats, even without signals from the larger nervous system of the human body. The SA and AV nodes initiate the electrical impulses that cause contraction within the atria and ventricles of the heart.

### Sinoatrial Node

The SA node is a bundle of nerve cells located on the outer layer of the right atria. These cells are specialized to undergo spontaneous depolarization and generation of action potentials without stimulation from the rest of the nervous system. The SA node nerve impulses travel through the atria and cause direct muscle cell depolarization and contraction of the atria. The SA node stimulates the right atria directly and stimulates the left atria through the Bachmann’s bundle. The SA node impulses also travel to the AV node, which stimulates ventricular contraction.

The SA node generates its own action potentials, but may be influenced by the autonomic nervous system. Without autonomic nervous stimulation, the SA node will set the heart rate itself, acting as the primary pacemaker for the heart. The SA node fires to set a heart rate in a range of 60–100 beats per minute (bpm), a normal range that varies from person to person.

### Atrioventricular Node

The AV node is a bundle of conducting tissue (not formally classified as nerve tissue) located at the junction between the atria and ventricles of the heart.  The AV node receives action potentials from the SA node, and transmits them through the bundle of His, left and right bundle branches, and Purkinje fibers, which cause depolarization of ventricular muscle cells leading to ventricular contraction. The AV node slightly slows the neural impulse from the SA node, which causes a delay between depolarization of the atria and the ventricles.

The normal firing rate in the AV node is lower than that of the SA node because it slows the rate of neural impulses. Without autonomic nervous stimulation, it sets the rate of ventricular contraction at 40–60 bpm. Certain types of autonomic nervous stimulation alter the rate of firing in the AV node. Sympathetic nervous stimulation still increases heart rate, while parasympathetic nervous stimulation decreases heart rate by acting on the AV node.

The Cardiac Conduction System: The system of nerves that work together to set the heart rate and stimulate muscle cell depolarization within the heart.

### Electrocardiogram and Correlation of ECG Waves with Systole

An electrocardiogram, or ECG, is a recording of the heart’s electrical activity as a graph over a period of time.

### Learning Objectives

Describe electrocardiograms and their correlation with systole

### Key Takeaways

#### Key Points

• An ECG is used to measure the rate and regularity of heartbeats as well as the size and position of the chambers, the presence of damage to the heart, and the effects of drugs or devices used to regulate the heart, such as a pacemaker.
• The ECG device detects and amplifies the tiny electrical changes on the skin that are caused when the heart muscle depolarizes during each heartbeat, and then translates the electrical pulses of the heart into a graphic representation.
• A typical ECG tracing of the cardiac cycle (heartbeat) consists of a P wave (atrial depolarization ), a QRS complex (ventricular depolarization), and a T wave (ventricular repolarization). An additional wave, the U wave ( Purkinje repolarization), is often visible, but not always.
• The ST complex is usually elevated during a myocardial infarction.
• Atrial fibrillation occurs when the P wave is missing and represents irregular, rapid, and inefficient atrial contraction, but is generally not fatal on its own.
• Ventricular fibrillation occurs when all normal waves of an ECG are missing, represents rapid and irregular heartbeats, and will quickly cause sudden cardiac death.

#### Key Terms

• fibrillation: A condition in which parts of the ECG do not appear normally, representing irregular, rapid, disorganized, and inefficient contractions of the atria or ventricles.
• ST segment: The line between the QRS complex and the T wave, representing the time when the ventricles are depolarized before repolarization begins.

An electrocardiogram (ECG or EKG) is a recording of the heart’s electrical activity as a graph over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body. The graph can show the heart’s rate and rhythm. It can also detect enlargement of the heart, decreased blood flow, or the presence of current or past heart attacks. ECGs are the primary clinical tool to measure electrical and mechanical performance of the heart.

The ECG works by detecting and amplifying tiny electrical changes on the skin that occur during heart muscle depolarization. The output for the ECG forms a graph that shows several different waves, each corresponding to a different electrical and mechanical event within the heart. Changes in these waves are used to identify problems with the different phases of heart activity.

ECG: Illustration of a patient undergoing a 12-lead ECG.

### The P Wave

Normal Systole ECG: The U wave is not visible in all ECGs.

The first wave on an ECG is the P wave, indicating atrial depolarization in which the atria contract (atrial systole ). The P wave is the first wave on the ECG because the  action potential for the heart is generated in the sinoatrial (SA) node, located on the atria, which sends action potentials directly through Bachmann’s bundle to depolarize the atrial muscle cells.

Increased or decreased P waves can indicate problems with the potassium ion concentration in the body that will alter nerve activity. A missing P wave indicates atrial fibrillation, a cardiac arrhythmia in which the heart beats irregularly, preventing efficient ventricular diastole. This is generally not fatal on its own.

### The QRS Complex

The QRS complex refers to the combination of the Q, R, and S waves, and indicates ventricular depolarization and contraction (ventricular systole). The Q and S waves are downward waves while the R wave, an upward wave, is the most prominent feature of an ECG. The QRS complex represents action potentials moving from the AV node, through the bundle of His and left and right branches and Purkinje fibers into the ventricular muscle tissue. Abnormalities in the QRS complex may indicate cardiac hypertrophy or myocardial infarctions.

### The T Wave and ST Segment

Animation of a Normal ECG Wave: The red lines represent the movement of the electrical signal through the heart.

The T Wave indicates ventricular repolarization, in which the ventricles relax following depolarization and contraction. The ST segment refers to the gap (flat or slightly upcurved line) between the S wave and the T wave, and represents the time between ventricular depolarization and repolarization. An elevated ST segment is the classic indicator for myocardial infarctions, though missing or downward sloping sloping ST segments may indicate myocardial ischemia.

Following the T wave is the U wave, which represents repolarization of the Purkinje fibers. It is not always visible on an ECG because it is a very small wave in comparison to the others.

### Ventricular Fibrillation

When ECG output shows no identifiable P waves, QRS complexes, or T waves, it imdicates ventricular fibrillation, a severe arrhythmia. During ventricular fibrillation, the heart beats extremely fast and irregularly and can no longer pump blood, acting as a mass of quivering, disorganized muscle movements. Ventricular fibrillation will cause sudden cardiac death within minutes unless electrical resuscitation (with an AED) is performed immediately. It generally occurs with myocardial infarcations and heart failure, and is thought to be caused by action potentials that re-enter the AV nodes from the muscle tissue and induce rapid, irregular, weak contractions of the heart that fail to pump blood.

### Heart Sounds

The two major heart sounds are “lub” (from the closure of AV valves) and “dub: (from the closure of aortic and pulmonary valves).

### Learning Objectives

Describe the sounds the heart makes

### Key Takeaways

#### Key Points

• The heart tone “lub,” or S1, is caused by the closure of the mitral and tricuspid atrioventricular (AV) valves at the beginning of ventricular systole.
• The heart tone “dub,” or S2 ( a combination of A2 and P2), is caused by the closure of the aortic valve and pulmonary valve at the end of ventricular systole.
• The splitting of the second heart tone, S2, into two distinct components, A2 and P2, can sometimes be heard in younger people during inspiration. During expiration, the interval between the two components shortens and the tones become merged.
• Murmurs are a “whoosh” or “slosh” sound that indicate backflow through the valves.
• S3 and S4 are a “ta” sound that indicates ventricles that are either too weak or too stiff to effectively pump blood.

#### Key Terms

• dub: The second heart tone, or S2 (A2 and P2), caused by the closure of the aortic valve and pulmonary valve at the end of ventricular systole.
• lub: The first heart tone, or S1,  caused by the closure of the atrioventricular valves (mitral and tricuspid) at the beginning of ventricular contraction or systole.
• Heart murmurs: A sound made by backflow of blood through either set of valve that cannot close or open properly.

The closing of the heart valves produces a sound. This sound may be described as either a “lub” or a “dub” sound. Heart sounds are a useful indicator for evaluating the health of the valves and the heart as a whole.

### S1

The first heart sound, called S1, makes a “lub” sound caused by the closure of the mitral and tricuspid valves as ventricular systole begins. There is a very slight split between the closure of the mitral and tricuspid valves, but it is not long enough to create multiple sounds.

### S2

The second heart sound, called S2, makes a “dub” sound caused by the closure of the semilunar (aortic and pulmonary) valves following ventricular systole. S2 is split because aortic valve closure occurs before pulmonary valve closure. During inspiration (breathing in) there is slightly increased blood return to the right side of the heart, which causes the pulmonary valve to stay open slightly longer than the aortic valve. Due to this, the naming convention is to divide the second sound into two second sounds, A2 (aortic), and P2 (pulmonary). The time between A2 and P2 is variable depending on the respiratory rate, but the split is generally only prominent in children during inspiration. In adults and during expiration, the split is usually not long enough to suggest two sounds.

### Abnormal Heart Sounds

Abnormal heart sounds may indicate problems with the health of the valves. Heart murmurs sound like a “whoosh” or “slosh” and indicate regurgitation or backflow of blood through the valves because they cannot close properly. Heart murmurs are common and generally not serious, but some may be more severe and/or caused by severe underlying problems within the heart. Murmurs may also be caused by valve stenosis (improper opening) and cardiac shunts, a severe condition in which a defect in the septum allows blood to flow between both sides of the heart.

Third and fourth heart sounds, S3 and S4, differ from S1 and S2 because they are caused by abnormal contraction and relaxation of the heart instead of the closure of valves and are more often indicative of more severe problems than are heart murmurs. S3 represents a flabby or weak ventricle that fills with more blood than it is able to pump, while S4 represents a stiff ventricle, such as those found in cardiac hypertrophy. S3 makes a “ta” sound after the “lub-dub” while S4 makes a “ta” sound before the “lub-dub.”

Opening and Closing of Heart Valves: The closing of the heart valves generates the “lub, dub” sounds that can be heard though a stethoscope.

### Cardiac Cycle

The cardiac cycle describes the heart’s phases of contraction and relaxation that drive blood flow throughout the body.

### Learning Objectives

Describe the cardiac cycle and its three phases

### Key Takeaways

#### Key Points

• Every single beat of the heart involves three major stages: cardiac diastole, when chambers are relaxed and filling passively; atrial systole when the atria contract leading to ventricular filling; and ventricular systole when blood is ejected into both the pulmonary artery and aorta.
• Pulse is a way of measuring heartbeat, based on the arterial distensions or pulses that occur as blood is pushed through the arteries.
• Resting heart rate typically ranges from 60 to 100 bpm (beats per minute). Athletes often have significantly lower than average heart rates while the sedentary and obese typically have elevated heart rates.
• Systolic blood pressure is the pressure during heart contraction, while diastolic blood pressure is the pressure during heart relaxation.
• The normal range for blood pressure is between 90/60 mmHg and 120/80 mmHg.

#### Key Terms

• cardiac cycle: The term used to describe the relaxation and contraction that occur as a heart works to pump blood through the body.
• cardiac output: The volume of blood pumped by the heart each minute, calculated as heart rate (HR) X (times) stroke volume (SV).
• pulse: Pressure waves generated by the heart in systole move the arterial walls, creating a palpable pressure wave felt by touch.

The cardiac cycle is the term used to describe the relaxation and contraction that occur as the heart works to pump blood through the body. Heart rate is a term used to describe the frequency of the cardiac cycle. It is considered one of the four vital signs and is a regulated variable. Usually heart rate is calculated as the number of contractions (heartbeats) of the heart in one minute and expressed as “beats per minute” (bpm). When resting, the adult human heart beats at about 70 bpm (males) and 75 bpm (females), but this varies among individuals. The reference range is normally between 60 bpm (lower is termed bradycardia) and 100 bpm (higher is termed tachycardia). Resting heart rates can be significantly lower in athletes and significantly higher in the obese. The body can increase the heart rate in response to a wide variety of conditions in order to increase the cardiac output, the blood ejected by the heart, which improves oxygen supply to the tissues.

### Pulse

Pressure waves generated by the heart in systole, or ventricular contraction, move the highly elastic arterial walls. Forward movement of blood occurs when the arterial wall boundaries are pliable and compliant. These properties allow the arterial wall to distend when pressure increases, resulting in a pulse that can be detected by touch. Exercise, environmental stress, or psychological stress can cause the heart rate to increase above the resting rate. The pulse is the most straightforward way of measuring the heart rate, but it can be a crude and inaccurate measurement when cardiac output is low. In these cases (as happens in some arrhythmias), there is little pressure change and no corresponding change in pulse, and the heart rate may be considerably higher than the measured pulse.

### Cardiac Cycle

Every single heartbeat includes three major stages: atrial systole, ventricular systole, and complete cardiac diastole.

• Atrial systole is the contraction of the atria that causes ventricular filling.
• Ventricular systole is the contraction of the ventricles in which blood is ejected into the pulmonary artery or aorta, depending on side.
• Complete cardiac diastole occurs after systole. The blood chambers of the heart relax and fill with blood once more, continuing the cycle.

### Systolic and Diastolic Blood Pressure

Throughout the cardiac cycle, the arterial blood pressure increases during the phases of active ventricular contraction and decreases during ventricular filling and atrial systole. Thus, there are two types of measurable blood pressure: systolic during contraction and diastolic during relaxation. Systolic blood pressure is always higher than diastolic blood pressure, generally presented as a ratio in which systolic blood pressure is over diastolic blood pressure. For example, 115/75 mmHg would indicated a systolic blood pressure of 115 mmHg and a diastolic blood pressure or 75 mmHG. The normal range for blood pressure is between 90/60 mmHg and 120/80 mmHg. Pressures higher than that range may indicate hypertension, while lower pressures may indicate hypotension. Blood pressure is a regulated variable that is directly related to blood volume, based on cardiac output during the cardiac cycle.

The Cardiac Cycle: Changes in contractility lead to pressure differences in the heart’s chambers that drive the movement of blood.

### Cardiac Output

Cardiac output (Q or CO) is the volume of blood pumped by the heart, in particular by the left or right ventricle, in one minute.

### Learning Objectives

Describe cardiac output and its function in the cardiovascular system

### Key Takeaways

#### Key Points

• Cardiac output, a measure of how much blood the heart pumps over the course of a minute, is calculated by multiplying heart rate by stroke volume.
• The heart rate is increased by sympathetic nervous stimulation and decreased by parasympathetic nervous stimulation.
• Stroke volume is end diastolic volume (venous return) minus end systolic volume, the amount of blood left over in the heart after systole.
• The ejection fraction is stroke volume divided by end diastolic volume.
• Mean arterial blood pressure is cardiac output multiplied by total peripheral resistance. A twofold change in vascular size will cause a 16-fold change in resistance in the opposite direction.
• Starling’s mechanism states that changes in venous return (preload) to the heart will change cardiac output, which will also change mean arterial blood pressure in the same direction. This means that blood volume and blood pressure are directly related to one another.

#### Key Terms

• mean arterial blood pressure: A measure of blood pressure based on cardiac output and vascular resistance.
• cardiac output: The volume of blood pumped by the heart, in particular by the left or right ventricle, in the time interval of one minute.

Cardiac output (CO) is a measure of the heart’s performance. While there are many clinical techniques to measure CO, it is best described as a physiological and mathematical relationship between different variables. When one of the variables change, CO as a whole will change as a result. This can also be used to predict other regulated variables, such as blood pressure and blood volume. The mathematical description of CO is that $\text{CO}=\text{Heart Rate (HR)}\times\text{Stroke Volume (SV)}$. Changes in HR, SV, or their components, will change CO.

### Heart Rate

The heart rate is determined by spontaneous action potential generation in the sinoatrial (SA) node and conduction in the atrioventricular (AV) node. It refers to the number of heartbeats over the course of a minute. Sympathetic nervous system activation will stimulate the SA and AV nodes to increase the heart rate, which will increase cardiac output. Parasympathetic nervous system activation will conversely act on the SA and AV nodes to decrease the heart rate, which will decrease cardiac output. For the SA node, the rate of depolarization is altered, while the AV node’s rate of conduction is altered by autonomic nerve stimulation.

### Stroke Volume

Stroke volume refers to the amount of blood ejected from the heart during a single beat. It is a measure of the contractility of the heart based on end diastolic volume (EDV), mathematically described as $\text{SV}=\text{EDV}-\text{ESV (end systolic volume}$. EDV is the volume of blood in the ventricles at the end of diastole, while ESV is the volume of blood left inside the ventricles at the end of systole, making SV the difference between EDV and ESV. Contractility of the heart refers to the variability in how much blood the heart ejects based on changes in stroke volume rather than than changes in heart rate.

Additionally, another indicator known as the ejection fraction (EF) is used to evaluate stroke volume and contractility. It is described as $\text{EF}=\left(\frac{\text{SV}}{\text{EDV}}\right)\times{100}\%$and is a measure of the proportion of blood ejected during systole compared to the amount of blood that was present in the heart. A higher EF suggests more efficient heart activity.

### Mean Arterial Pressure

Cardiac output is an indicator of mean arterial blood pressure (MAP), the average measure of blood pressure within the body. It is described as $\text{MAP}=\text{CO}\times\text{TPR (total peripheral resistance)}$. TPR is a measure of resistance in the blood vessels, which acts as the force by which blood must overcome to flow through the arteries determined by the diameter of the blood vessels. The exact relationship is such that a twofold increase in blood vessel diameter (doubling the diameter) would decrease resistance by 16-fold, and the opposite is true as well. When CO increases, MAP will increase, but if CO decreases, MAP will decrease.

### Starling’s Law of the Heart

Frank Starling’s Law: This chart indicates stroke volume compared to ventricular preload, with labels for preload dependent zone, responsive patient SVV > 10%, and nonresponsive patient SVV < 10 %.

CO can also predict blood pressure based on blood volume. Starling’s law of the heart states that the SV of the heart increases in response to an increase in EDV when all other factors remain constant. Essentially, this means that higher venous blood return to the heart (also called the preload) will increase SV, which will in turn increase CO. This is because sarcomeres are stretched further when EDV increases, allowing the heart to eject more blood and keep the same ESV if no other factors change.

The main implication of this law is that increases in blood volume or blood return to the heart will increase cardiac output, which will lead to an increase in MAP. The opposite scenario is true as well. For example, a dehydrated person will have a low blood volume and lower venous return to the heart, which will decrease cardiac output and blood pressure. Those that stand up quickly after lying down may feel light-headed because their venous return to the heart is momentarily impaired by gravity, temporarily decreasing blood pressure and supply to the brain. The adjustment for blood pressure is a quick process, while blood volume is slowly altered. Blood volume itself is another regulated variable, regulated slowly through complex processes in the renal system that alter blood pressure based on the Starling mechanism.

Sours: https://courses.lumenlearning.com/boundless-ap/chapter/physiology-of-the-heart/

## Leopold Maneuvers

### Continuing Education Activity

The Leopold maneuvers are used to palpate the gravid uterus systematically. This method of abdominal palpation is of low cost, easy to perform, and non-invasive. It is used to determine the position, presentation, and engagement of the fetus in utero. This activity describes the four Leopold maneuvers and explains the method of systematic abdominal palpation used to assess fetal presentation and position in the third trimester of pregnancy.

Objectives:

• Describe the normal fetal presentation and position.

• Explain the four Leopold maneuvers.

• Summarize the clinical significance of abdominal palpation in the obstetric examination.

• Identify the importance of improving training in abdominal palpation to enhance the delivery of care for obstetric patients.

Access free multiple choice questions on this topic.

### Introduction

The Leopold maneuvers, named after the German obstetrician and gynecologist Christian Gerhard Leopold (1846–1911), are part of the physical examination of pregnant women.[1][2] Four classical maneuvers are used to palpate the gravid uterus systematically. This method of abdominal palpation is of low cost, easy to perform, and non-invasive. It is used to determine the position, presentation, and engagement of the fetus in utero.

Fetal presentation refers to the fetal anatomic part proceeding first into the pelvic inlet. When the fetal head is approaching the pelvic inlet, it is referred to as a cephalic presentation. The commonest presentation is the vertex of the fetal head. Malpositions are abnormal positions of the vertex of the fetal head, using the occiput as the reference point, relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex, which includes the breech presentation, transverse and oblique lie. Spontaneous vaginal delivery is most common when a cephalic-presenting fetus is in the occiput anterior position.[3]

Malpresentation is estimated to occur in 5% of all deliveries and is an essential cause of the high cesarean delivery rate.[4] It is essential to detect non-cephalic presentations before the onset of labor to mitigate the maternal and neonatal risks associated with complicated vaginal delivery or cesarean section. Detection of malpresentation in late pregnancy allows for counseling on adequate care measures. The underutilized external cephalic version and intrapartum planning and consenting are choices that can be discussed.[5][6][7]

Accurate assessment of fetal presentation and position is crucial in guiding obstetric management. However, the accuracy of Leopold maneuvers varies depending on many factors, especially examiner experience. Therefore ultrasonographic examination remains the current gold standard investigation for ensuring the fetus is in the cephalic presentation during the third trimester of pregnancy. It is recommended for confirmation when any malpresentation is even slightly suspected.[8][9]

### Indications

Palpation is the contact of the operator's fingers and hands with the body of the woman or child. It offers the possibility of collecting data on an area, structure, or function by touch. Uterine contractions, the size of the pregnant uterus, any uterine masses, and attitude, presentation, degree of commitment of the fetus, and any fetal-pelvic disproportions can be detected.

Abdominal palpation is accurate in identifying the presentation, mainly if performed by experienced healthcare professionals. If in doubt about the presentation part, obstetric ultrasound should be used to confirm the results of the palpation. Ultrasound can also rule out fetal abnormalities, low placenta, hyperextension of the baby's head, and the presence of the umbilical cord around the neck of the fetus. The palpation technique requires skill and delicacy. The entire palm and fingers are useful for detecting myometrial activity, fetal movements, or any neoformations (fibroids), or the degree of edema. Palpation can be superficial or deep (the superficial one must always precede the deep one since the latter can cause pain); avoid having long nails because they can cause discomfort or injury.

From a psychological point of view, palpation is to be considered a form of analog communication between the midwife and the woman. Therefore through this technique, the operator can transmit the feelings they have towards the patient.

### Contraindications

While the benefits of abdominal palpation are challenging to quantify, the risks have not been identified. Evaluation of presentation by abdominal palpation before 36 weeks is not always accurate. Routine evaluation of the presentation with abdominal palpation should not be offered before 36 weeks, due to any inaccuracies and inconvenience to the woman. The fetal presentation should be evaluated with the abdominal palpation at 36 weeks or later when the presentation can affect plans for childbirth.

Leopold maneuvers are complicated maneuvers to perform on obese women and women who have polyhydramnios. Palpation can sometimes be uncomfortable for the patient if no precautions are taken to ensure that she is well-positioned and relaxed.

### Preparation

The aim of Leopold maneuvers is to determine the fetal presentation and position by systematically palpating the gravid abdomen. The initial steps are described below:

1. Wash hands

2. Explain the steps of the examination to the patient as this reduces anxiety and enhances cooperation

3. Obtain consent

4. The patient should be advised to void as an empty bladder promotes comfort and allows for more productive examination, and the distended bladder can obscure fetal contour

5. Provision of privacy

6. Prepare the equipment, such as measuring tape, Pinard stethoscope or Doppler transducer, and ultrasound gel

7. Position the patient supine with the head of the bed raised to 15 degrees, and a small pillow or rolled towel placed on her right side

8. Adequate exposure of the gravid abdomen from the xiphisternum to the pubic symphysis

9. Inspect the gravid abdomen

### Technique

The First Maneuver

The first maneuver also called the fundal grip, assesses the uterine fundus to determine its height and which fetal pole—that is, cephalic or podalic—occupies the fundus. The uterine contour is outlined by the examiner, placing both of his or her hands on each upper quadrant of the patient's abdomen facing the maternal xiphoid cartilage. The ulnar border of each hand is in contact with the abdominal wall, and the opposite fingers are touching each other. Using the fingertips, the fundus is gently palpated to identify which fetal part is present in the upper pole (fundus) of the uterus. The breach gives the sensation of a large, nodular mass, and its surface is uneven, non-ballotable, and not very mobile whereas the head feels hard and round with a smooth surface of uniform consistency, is very mobile and ballotable.

The first maneuver aims to determine the gestational age and the fetal lie.

Gestational age can be evaluated using fundal height or McDonald's rule.[1] The uterine fundus reaches:

• The public symphysis at the 12th week

• A point midway between the pubic symphysis and the transverse and the transverse umbilical plane at the 16th week

• The transverse umbilical plane at the 20th week

• Having crossed this line, it is assumed each transverse finger breath corresponds to two weeks

The Second Maneuver

The second maneuver, sometimes called the umbilical grip, involves palpation of the lateral uterine surfaces. Still facing the maternal xiphoid cartilage, both hands slide down from the uterine fundus towards the lateral uterine walls. The clinician's hands are placed flat and parallel to each other along the abdominal wall at the level of the umbilicus. It allows establishing if the fetus is in a longitudinal, transverse, or oblique situation, and to determine the position of the back and small parts.The operator places the two flat hands sideways to the uterus and tries to bring them closer to the midline. In the approach maneuvers, the operator's hands are one on the back of the fetus and one on the small parts, which give different tactile sensations.The approach is possible when the fetus is in a longitudinal position regardless of the type of presentation, while it is not possible when the situation is transverse or oblique. Furthermore, it is possible to understand from which side the fetal back is located.

If the identification of the fetal back proves to be difficult, the provider can perform the following maneuvers. A simple adjustment involves alternating two hand palpation of lateral uterine surfaces. By placing the right hand steady on one side of the abdomen while using the palm of the left hand, the right side of the gravid uterus is palpated gently. This is then repeated using the opposite side. Otherwise, the Budin maneuver, named after French obstetrician and gynecologist Pierre-Constant Budin 1846–1907, can be performed for the precise determination of the position of the fetal back.[2] The uterine fundus is pressed with force using one hand, which accentuates the curvature of the fetal back, allowing for easier palpation with the other hand. The fetal heart can be auscultated at this time, which can also provide information on fetal orientation. The heart is well perceived when the stethoscope or the doppler transducer is placed on the back of the fetus.

The Third Maneuver

The third maneuver was modified by Karel Pawlík (1849–1914), a Czech gynecologist and obstetrician, and is referred to as the Pawlik grips. This maneuver aids in the confirmation of fetal presentation.

The first Pawlík grip, sometimes called the first pelvic grip, helps to define which presenting part of the fetus is situated in hypogastrium. Using the thumb and fingers of the right hand close above the pubic symphysis, the presenting part is grasped at the lower portion of the abdomen and draws the thumb and finger near to clasp the lower uterine segment including its contents.

In the second Pawlík grip, the clinician carries on by sliding the hand upward to determine the cervical groove: if the mass moves, the presenting part is not engaged. Then lateral movements and ballottement are performed. The differentiation between head and breech is made as in the first maneuver. This maneuver also allows for an assessment of the fetal weight and the volume of amniotic fluid.

The Fourth Maneuver

This fourth maneuver resembles the first maneuver; however, the examiner faces towards the maternal pelvis. This maneuver involves the examiner placing the palms of both hands on either side of the lower abdomen, with the tips of the fingers facing downward toward the pelvic inlet. The fingertips of each hand are used to apply deep pressure from the outside to the inside and in a craniocaudal direction along the lower contour of the uterus towards the birth canal. It is possible to identify the characteristics of the part presented and confirm the findings detected with the third Leopold maneuver. The fingers of both hands move gently along the sides of the uterus towards the pubis. The side where there is resistance to the descent of the fingers towards the pubis is larger is where the forehead is located. If the head of the fetus is well flexed, it should be on the opposite side from the back of the fetus. If the head of the fetus is extended, however, the occiput is perceived and is on the same side of the spine. It is possible to evaluate the degree of descent of the presented part and to realize if there are gross disproportions between this and the pelvic inlet.

This maneuver identifies which presenting part is in the lower uterine pole. To perceive how much of the cephalic extremity, which we recognized to be at the lower pole, descends into the birth canal: if it is entirely external, then it has not confronted itself, if it is confronting itself or if it has ultimately descended. The fingers travel the upper contour of the cephalic end, around the neck of the fetus.

Completing the fourth maneuver with the so-called "fifth maneuver" of Leopold, or maneuver of Zagenmeister, also can allow the approximate distance between the presenting part and the maternal pelvis. In the cephalic presentation, the hand is placed flat on the pubic symphysis, and the palpation could delineate the fetal head portion that can be reached above the pelvic inlet. Using the rule of fifths, the distance between the base and vertex of the fetal head is divided into five equal parts. Each fifth corresponding to 2 cm or approximately one transverse fingerbreadth. If the fetal head accommodates two fingerbreadths above the pelvic brim, it is said to be engaged.

### Complications

A breech presentation occurs when the presenting part is either the buttocks and/or the feet. On examination, the head is felt in the upper uterine pole and the breech in the pelvic cavity. The fetal heart tones are auscultated higher than anticipated with a vertex presentation.

When the longest axis of the fetus is oriented transversely, the presenting part is typically the shoulder. In the transverse lie on palpation, neither the head nor the buttocks can be palpated in the lower uterine pole inlet, and the fetal head can be felt in the flank.

Occiput posterior position occurs when the fetal occiput is at or posterior to the sacroiliac joint. On examination, there is a lower abdomen flattened, fetal limbs are palpable anteriorly, and the fetal heart tones may be auscultated in the flank.

Brow presentation occurs with some extension of the fetal head. On palpation, the fetal occiput is higher than the sinciput, and more than half the fetal head is felt above the symphysis pubis.

Face presentation results from hyperextension of the fetal head.  On palpation, the fold of the neck is felt as a deep indentation between the occiput and the back; however, in face presentation, this depression is limited.

### Clinical Significance

Few studies have compared the gold standard ultrasonography with clinical examination to detect non-cephalic presentation in the third trimester of pregnancy. These investigators found that abdominal palpation fails to detect a significant percentage of mal-presenting fetuses.[3]

Clinical examination was relatively sensitive in multiparous women and those with lower body mass indices. The specificity of clinical examination increased significantly as gestational age increased, and body mass index decreased. When abdominal palpation was evaluated as a screening tool for identifying malpresentation, it was found that false-positive diagnoses were a more frequent error because of the low prevalence of malpresentation in low-risk populations.[4]

Leopold maneuvers have been reported to be difficult in obese pregnant women and pregnancies complicated with polyhydramnios, fibroids, or anterior placental location. In clinical practice, the use of repeated procedures by a second examiner, pelvic examination, and rescheduling a return visit with a sequential abdominal examination can serve to improve the accuracy of abdominal palpation findings.

Leopold maneuvers can help mothers to perceive and visualize fetuses. Thus abdominal palpations can develop the maternal-fetal relationship, which plays an important role in a child's psychological, cognitive, and social development.[5][6][7]

### Enhancing Healthcare Team Outcomes

All healthcare providers should be competent with the methods to perform abdominal palpation of a gravid uterus and the significance of the findings. The findings observed should be documented and can be used to guide further obstetric management. Identifying pregnancies complicated by malpresentation and referral to appropriate facilities may lead to improved outcomes for both neonate and mother.[8]

Offering an external cephalic version (ECV) for breech presentation can contribute to the safe lowering of the primary cesarean delivery rate.[9] Training for existing or new staff who are moving to midwifery-obstetric care is necessary as experienced clinicians can be effective in using abdominal palpation as a screening tool for fetal malpresentation, particularly in settings where ultrasound may not be readily available.[4]

#### Figure

Leopold Maneuvers (A) , First Maneuver (B) Second Maneuver (C) Third Maneuver (D) Fourth Maneuver. Illustrated by Junior Maloney

### References

1.

McCowan LM, Figueras F, Anderson NH. Evidence-based national guidelines for the management of suspected fetal growth restriction: comparison, consensus, and controversy. Am J Obstet Gynecol. 2018 Feb;218(2S):S855-S868. [PubMed: 29422214]

2.

Toubas PL. Dr. Pierre Budin: promoter of breastfeeding in 19th century France. Breastfeed Med. 2007 Mar;2(1):45-9. [PubMed: 17661619]

3.

Nassar N, Roberts CL, Cameron CA, Olive EC. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ. 2006 Sep 16;333(7568):578-80. [PMC free article: PMC1570002] [PubMed: 16891327]

4.

Lydon-Rochelle M, Albers L, Gorwoda J, Craig E, Qualls C. Accuracy of Leopold maneuvers in screening for malpresentation: a prospective study. Birth. 1993 Sep;20(3):132-5. [PubMed: 8240620]

5.

Celik M, Ergin A. The effect on pregnant women's prenatal attachment of a nursing practice using the first and second Leopold's maneuvers. Jpn J Nurs Sci. 2020 Apr;17(2):e12297. [PubMed: 31762185]

6.

Nishikawa M, Sakakibara H. Effect of nursing intervention program using abdominal palpation of Leopold's maneuvers on maternal-fetal attachment. Reprod Health. 2013 Feb 19;10:12. [PMC free article: PMC3599122] [PubMed: 23421578]

7.

Waters E, Merrick S, Treboux D, Crowell J, Albersheim L. Attachment security in infancy and early adulthood: a twenty-year longitudinal study. Child Dev. 2000 May-Jun;71(3):684-9. [PubMed: 10953934]

8.

Duffy CR, Moore JL, Saleem S, Tshefu A, Bose CL, Chomba E, Carlo WA, Garces AL, Krebs NF, Hambidge KM, Goudar SS, Derman RJ, Patel A, Hibberd PL, Esamai F, Liechty EA, Wallace DD, McClure EM, Goldenberg RL., NICHD Global Network for Women's and Children's Health Research. Malpresentation in low- and middle-income countries: Associations with perinatal and maternal outcomes in the Global Network. Acta Obstet Gynecol Scand. 2019 Mar;98(3):300-308. [PMC free article: PMC6422525] [PubMed: 30414270]

9.

Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 Mar;123(3):693-711. [PubMed: 24553167]

Sours: https://www.ncbi.nlm.nih.gov/books/NBK560814/
Heart Sounds and Heart Murmurs, Animation.

### Learning Objectives

By the end of this section, you will be able to:

• Describe the relationship between blood pressure and blood flow
• Summarize the events of the cardiac cycle
• Compare atrial and ventricular systole and diastole
• Relate heart sounds detected by auscultation to action of heart’s valves

The period of time that begins with contraction of the atria and ends with ventricular relaxation is known as the cardiac cycle. The period of contraction that the heart undergoes while it pumps blood into circulation is called systole. The period of relaxation that occurs as the chambers fill with blood is called diastole. Both the atria and ventricles undergo systole and diastole, and it is essential that these components be carefully regulated and coordinated to ensure blood is pumped efficiently to the body.

Figure 1. The cardiac cycle begins with atrial systole and progresses to ventricular systole, atrial diastole, and ventricular diastole, when the cycle begins again. Correlations to the ECG are highlighted.

### Pressures and Flow

Fluids, whether gases or liquids, are materials that flow according to pressure gradients—that is, they move from regions that are higher in pressure to regions that are lower in pressure. Accordingly, when the heart chambers are relaxed (diastole), blood will flow into the atria from the veins, which are higher in pressure. As blood flows into the atria, the pressure will rise, so the blood will initially move passively from the atria into the ventricles. When the action potential triggers the muscles in the atria to contract (atrial systole), the pressure within the atria rises further, pumping blood into the ventricles. During ventricular systole, pressure rises in the ventricles, pumping blood into the pulmonary trunk from the right ventricle and into the aorta from the left ventricle. Again, as you consider this flow and relate it to the conduction pathway, the elegance of the system should become apparent.

### Phases of the Cardiac Cycle

At the beginning of the cardiac cycle, both the atria and ventricles are relaxed (diastole). Blood is flowing into the right atrium from the superior and inferior venae cavae and the coronary sinus. Blood flows into the left atrium from the four pulmonary veins. The two atrioventricular valves, the tricuspid and mitral valves, are both open, so blood flows unimpeded from the atria and into the ventricles. Approximately 70–80 percent of ventricular filling occurs by this method. The two semilunar valves, the pulmonary and aortic valves, are closed, preventing backflow of blood into the right and left ventricles from the pulmonary trunk on the right and the aorta on the left.

### Atrial Systole and Diastole

Contraction of the atria follows depolarization, represented by the P wave of the ECG. As the atrial muscles contract from the superior portion of the atria toward the atrioventricular septum, pressure rises within the atria and blood is pumped into the ventricles through the open atrioventricular (tricuspid, and mitral or bicuspid) valves. At the start of atrial systole, the ventricles are normally filled with approximately 70–80 percent of their capacity due to inflow during diastole. Atrial contraction, also referred to as the “atrial kick,” contributes the remaining 20–30 percent of filling (see the image below). Atrial systole lasts approximately 100 ms and ends prior to ventricular systole, as the atrial muscle returns to diastole.

### Ventricular Systole

Ventricular systole (see image below) follows the depolarization of the ventricles and is represented by the QRS complex in the ECG. It may be conveniently divided into two phases, lasting a total of 270 ms. At the end of atrial systole and just prior to atrial contraction, the ventricles contain approximately 130 mL blood in a resting adult in a standing position. This volume is known as the end diastolic volume (EDV) or preload.

Initially, as the muscles in the ventricle contract, the pressure of the blood within the chamber rises, but it is not yet high enough to open the semilunar (pulmonary and aortic) valves and be ejected from the heart. However, blood pressure quickly rises above that of the atria that are now relaxed and in diastole. This increase in pressure causes blood to flow back toward the atria, closing the tricuspid and mitral valves. Since blood is not being ejected from the ventricles at this early stage, the volume of blood within the chamber remains constant. Consequently, this initial phase of ventricular systole is known as isovolumic contraction, also called isovolumetric contraction (see image below).

In the second phase of ventricular systole, the ventricular ejection phase, the contraction of the ventricular muscle has raised the pressure within the ventricle to the point that it is greater than the pressures in the pulmonary trunk and the aorta. Blood is pumped from the heart, pushing open the pulmonary and aortic semilunar valves. Pressure generated by the left ventricle will be appreciably greater than the pressure generated by the right ventricle, since the existing pressure in the aorta will be so much higher. Nevertheless, both ventricles pump the same amount of blood. This quantity is referred to as stroke volume. Stroke volume will normally be in the range of 70–80 mL. Since ventricular systole began with an EDV of approximately 130 mL of blood, this means that there is still 50–60 mL of blood remaining in the ventricle following contraction. This volume of blood is known as the end systolic volume (ESV).

### Ventricular Diastole

Ventricular relaxation, or diastole, follows repolarization of the ventricles and is represented by the T wave of the ECG. It too is divided into two distinct phases and lasts approximately 430 ms.

During the early phase of ventricular diastole, as the ventricular muscle relaxes, pressure on the remaining blood within the ventricle begins to fall. When pressure within the ventricles drops below pressure in both the pulmonary trunk and aorta, blood flows back toward the heart, producing the dicrotic notch (small dip) seen in blood pressure tracings. The semilunar valves close to prevent backflow into the heart. Since the atrioventricular valves remain closed at this point, there is no change in the volume of blood in the ventricle, so the early phase of ventricular diastole is called the isovolumic ventricular relaxation phase, also called isovolumetric ventricular relaxation phase (see image below).

In the second phase of ventricular diastole, called late ventricular diastole, as the ventricular muscle relaxes, pressure on the blood within the ventricles drops even further. Eventually, it drops below the pressure in the atria. When this occurs, blood flows from the atria into the ventricles, pushing open the tricuspid and mitral valves. As pressure drops within the ventricles, blood flows from the major veins into the relaxed atria and from there into the ventricles. Both chambers are in diastole, the atrioventricular valves are open, and the semilunar valves remain closed (see image below). The cardiac cycle is complete. Figure 2 illustrates the relationship between the cardiac cycle and the ECG.

Figure 2. Initially, both the atria and ventricles are relaxed (diastole). The P wave represents depolarization of the atria and is followed by atrial contraction (systole). Atrial systole extends until the QRS complex, at which point, the atria relax. The QRS complex represents depolarization of the ventricles and is followed by ventricular contraction. The T wave represents the repolarization of the ventricles and marks the beginning of ventricular relaxation.

### Heart Sounds

One of the simplest, yet effective, diagnostic techniques applied to assess the state of a patient’s heart is auscultation using a stethoscope.

In a normal, healthy heart, there are only two audible heart sounds: S1 and S2. S1 is the sound created by the closing of the atrioventricular valves during ventricular contraction and is normally described as a “lub,” or first heart sound. The second heart sound, S2, is the sound of the closing of the semilunar valves during ventricular diastole and is described as a “dub” (Figure 3). In both cases, as the valves close, the openings within the atrioventricular septum guarded by the valves will become reduced, and blood flow through the opening will become more turbulent until the valves are fully closed. There is a third heart sound, S3, but it is rarely heard in healthy individuals. It may be the sound of blood flowing into the atria, or blood sloshing back and forth in the ventricle, or even tensing of the chordae tendineae. S3 may be heard in youth, some athletes, and pregnant women. If the sound is heard later in life, it may indicate congestive heart failure, warranting further tests. Some cardiologists refer to the collective S1, S2, and S3 sounds as the “Kentucky gallop,” because they mimic those produced by a galloping horse. The fourth heart sound, S4, results from the contraction of the atria pushing blood into a stiff or hypertrophic ventricle, indicating failure of the left ventricle. S4 occurs prior to S1 and the collective sounds S4, S1, and S2 are referred to by some cardiologists as the “Tennessee gallop,” because of their similarity to the sound produced by a galloping horse with a different gait. A few individuals may have both S3 and S4, and this combined sound is referred to as S7.

Figure 3. In this illustration, the x-axis reflects time with a recording of the heart sounds. The y-axis represents pressure.

The term murmur is used to describe an unusual sound coming from the heart that is caused by the turbulent flow of blood. Murmurs are graded on a scale of 1 to 6, with 1 being the most common, the most difficult sound to detect, and the least serious. The most severe is a 6. Phonocardiograms or auscultograms can be used to record both normal and abnormal sounds using specialized electronic stethoscopes.

During auscultation, it is common practice for the clinician to ask the patient to breathe deeply. This procedure not only allows for listening to airflow, but it may also amplify heart murmurs. Inhalation increases blood flow into the right side of the heart and may increase the amplitude of right-sided heart murmurs. Expiration partially restricts blood flow into the left side of the heart and may amplify left-sided heart murmurs. Figure 4 indicates proper placement of the bell of the stethoscope to facilitate auscultation.

Figure 4. Proper placement of the bell of the stethoscope facilitates auscultation. At each of the four locations on the chest, a different valve can be heard.

### Chapter Review

The cardiac cycle comprises a complete relaxation and contraction of both the atria and ventricles, and lasts approximately 0.8 seconds. Beginning with all chambers in diastole, blood flows passively from the veins into the atria and past the atrioventricular valves into the ventricles. The atria begin to contract (atrial systole), following depolarization of the atria, and pump blood into the ventricles. The ventricles begin to contract (ventricular systole), raising pressure within the ventricles. When ventricular pressure rises above the pressure in the atria, blood flows toward the atria, producing the first heart sound, S1 or lub. As pressure in the ventricles rises above two major arteries, blood pushes open the two semilunar valves and moves into the pulmonary trunk and aorta in the ventricular ejection phase. Following ventricular repolarization, the ventricles begin to relax (ventricular diastole), and pressure within the ventricles drops. As ventricular pressure drops, there is a tendency for blood to flow back into the atria from the major arteries, producing the dicrotic notch in the ECG and closing the two semilunar valves. The second heart sound, S2 or dub, occurs when the semilunar valves close. When the pressure falls below that of the atria, blood moves from the atria into the ventricles, opening the atrioventricular valves and marking one complete heart cycle. The valves prevent backflow of blood. Failure of the valves to operate properly produces turbulent blood flow within the heart; the resulting heart murmur can often be heard with a stethoscope.

### Self Check

Answer the question(s) below to see how well you understand the topics covered in the previous section.

### Critical Thinking Question

Describe one cardiac cycle, beginning with both atria and ventricles relaxed.

Show an Example Answer

The cardiac cycle comprises a complete relaxation and contraction of both the atria and ventricles, and lasts approximately 0.8 seconds. Beginning with all chambers in diastole, blood flows passively from the veins into the atria and past the atrioventricular valves into the ventricles. The atria begin to contract following depolarization of the atria and pump blood into the ventricles. The ventricles begin to contract, raising pressure within the ventricles. When ventricular pressure rises above the pressure in the two major arteries, blood pushes open the two semilunar valves and moves into the pulmonary trunk and aorta in the ventricular ejection phase. Following ventricular repolarization, the ventricles begin to relax, and pressure within the ventricles drops. When the pressure falls below that of the atria, blood moves from the atria into the ventricles, opening the atrioventricular valves and marking one complete heart cycle.

### Glossary

cardiac cycle period of time between the onset of atrial contraction (atrial systole) and ventricular relaxation (ventricular diastole)

diastole:: period of time when the heart muscle is relaxed and the chambers fill with blood

end diastolic volume (EDV): (also, preload) the amount of blood in the ventricles at the end of atrial systole just prior to ventricular contraction

end systolic volume (ESV): amount of blood remaining in each ventricle following systole

heart sounds: sounds heard via auscultation with a stethoscope of the closing of the atrioventricular valves (“lub”) and semilunar valves (“dub”)

isovolumic contraction: also, isovolumetric contraction) initial phase of ventricular contraction in which tension and pressure in the ventricle increase, but no blood is pumped or ejected from the heart

isovolumic ventricular relaxation phase: initial phase of the ventricular diastole when pressure in the ventricles drops below pressure in the two major arteries, the pulmonary trunk, and the aorta, and blood attempts to flow back into the ventricles, producing the dicrotic notch of the ECG and closing the two semilunar valves

murmur: unusual heart sound detected by auscultation; typically related to septal or valve defects

preload: (also, end diastolic volume) amount of blood in the ventricles at the end of atrial systole just prior to ventricular contraction

systole: period of time when the heart muscle is contracting

ventricular ejection phase: second phase of ventricular systole during which blood is pumped from the ventricle

Sours: https://courses.lumenlearning.com/suny-ap2/chapter/cardiac-cycle/

## 17.4C: Heart Sounds

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The two major heart sounds are “lub” (from the closure of AV valves) and “dub: (from the closure of aortic and pulmonary valves).

Learning Objectives

• Describe the sounds the heart makes

### Key Points

• The heart tone “lub,” or S1, is caused by the closure of the mitral and tricuspid atrioventricular (AV) valves at the beginning of ventricular systole.
• The heart tone “dub,” or S2 ( a combination of A2 and P2), is caused by the closure of the aortic valve and pulmonary valve at the end of ventricular systole.
• The splitting of the second heart tone, S2, into two distinct components, A2 and P2, can sometimes be heard in younger people during inspiration. During expiration, the interval between the two components shortens and the tones become merged.
• Murmurs are a “whoosh” or “slosh” sound that indicate backflow through the valves.
• S3 and S4 are a “ta” sound that indicates ventricles that are either too weak or too stiff to effectively pump blood.

### Key Terms

• dub: The second heart tone, or S2 (A2 and P2), caused by the closure of the aortic valve and pulmonary valve at the end of ventricular systole.
• lub: The first heart tone, or S1, caused by the closure of the atrioventricular valves (mitral and tricuspid) at the beginning of ventricular contraction or systole.
• Heart murmurs: A sound made by backflow of blood through either set of valve that cannot close or open properly.

The closing of the heart valves produces a sound. This sound may be described as either a “lub” or a “dub” sound. Heart sounds are a useful indicator for evaluating the health of the valves and the heart as a whole.

### S1

The first heart sound, called S1, makes a “lub” sound caused by the closure of the mitral and tricuspid valves as ventricular systole begins. There is a very slight split between the closure of the mitral and tricuspid valves, but it is not long enough to create multiple sounds.

### S2

The second heart sound, called S2, makes a “dub” sound caused by the closure of the semilunar (aortic and pulmonary) valves following ventricular systole. S2 is split because aortic valve closure occurs before pulmonary valve closure. During inspiration (breathing in) there is slightly increased blood return to the right side of the heart, which causes the pulmonary valve to stay open slightly longer than the aortic valve. Due to this, the naming convention is to divide the second sound into two second sounds, A2 (aortic), and P2 (pulmonary). The time between A2 and P2 is variable depending on the respiratory rate, but the split is generally only prominent in children during inspiration. In adults and during expiration, the split is usually not long enough to suggest two sounds.

### Abnormal Heart Sounds

Abnormal heart sounds may indicate problems with the health of the valves. Heart murmurs sound like a “whoosh” or “slosh” and indicate regurgitation or backflow of blood through the valves because they cannot close properly. Heart murmurs are common and generally not serious, but some may be more severe and/or caused by severe underlying problems within the heart. Murmurs may also be caused by valve stenosis (improper opening) and cardiac shunts, a severe condition in which a defect in the septum allows blood to flow between both sides of the heart.

Third and fourth heart sounds, S3 and S4, differ from S1 and S2 because they are caused by abnormal contraction and relaxation of the heart instead of the closure of valves and are more often indicative of more severe problems than are heart murmurs. S3 represents a flabby or weak ventricle that fills with more blood than it is able to pump, while S4 represents a stiff ventricle, such as those found in cardiac hypertrophy. S3 makes a “ta” sound after the “lub-dub” while S4 makes a “ta” sound before the “lub-dub.”

Opening and Closing of Heart Valves: The closing of the heart valves generates the “lub, dub” sounds that can be heard though a stethoscope.

Sours: https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Book%3A_Anatomy_and_Physiology_(Boundless)/17%3A_Cardiovascular_System%3A_The_Heart/17.4%3A_Physiology_of_the_Heart/17.4C%3A_Heart_Sounds
S3 Heart Sound - MEDZCOOL

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Their steadfast determination ensures efficient and quality patient care, as well as safety. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. D) Secretions may be retained. View Report (85). Rarely, if there are concerns …. Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. com, INC, 7900 International Drive #300, Bloomington MN 55425 1-612-816-8773. 2°F oral, blood pressure 84/50. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress. pdf from NR 327 at Chamberlain College of Nursing. A nurse is examining an elderly patient who presents to the emergency department complaining of shortness of breath. Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Question nurse toni is reviewing the handout about iv pain medications during labor with claire. A nurse is caring for a client who is hospitalized and asks to review his medical record. d) Notify the physician. c) Assess for bleeding. This is a private class. 2°F oral, blood pressure 84/50. Optimal Decision Scenario The nurses are reviewing Apgar scoring Question Nurse from ENGLISH 204 at Alabama A&M University. When assessing the patient for heart sounds, the nurse must first obtain a patient history; inspection, palpation and possibly percussion will also usually be performed before you begin to auscultate. Il vocabolo originariamente significava anche "corteccia", ma visto che era un materiale usato per scrivere testi (in libro scribuntur litterae, Plauto), in seguito per estensione la parola ha assunto il significato di "opera letteraria". The appropriate response by the nurse is A. Make sure this fitsby entering your model number. Newborn rash, erythema toxicum, is a common finding in newborns …. Nurse Toni Is Reviewing The Handout About Iv Pain. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. 002 Fluid, Electrolyte and Acid-Base Imbalances - 37 cards. Rationale Opioid analgesics cross the placenta and can cause respiratory depression in the newborn. A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. pdf from NR 452 at Chamberlain College of Nursing. A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Module Report Tutorial: Real Life RN Maternal Newborn 3. A patient is admitted with a broken hip. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. What should the nurse do first? a) Review the patient’s preoperative vital signs. 001 Introduction to Pathophysiology - 65 cards. Identify. com/advert/le-casino-cafe-de-paris-monte-carlo-bres-everlasting-beauty/. A nurse is caring for a client who is hospitalized and asks to review his medical record. The nursing process (assessment, analysis, planning, implementation, and evaluation) Caring Communication and documentation Teaching and learning The following scenarios illustrate how NCLEX items combine integrated processes and client need categories. Professional academic writers. Nurse Toni Is Reviewing The Handout About Iv Pain. Cookies are currently enabled to maximize your TeePublic experience. THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL SATURDAY, MAY SEVENTEENTH AND SUNDAY, MAY EIGHTEENTH TWO THOUSAND THREE 1 Digitized by the Internet Archive in 2013. pdf from NR 452 at Chamberlain College of Nursing. Nursing Flashcards. The nurses assessment reveals that she has a history of asthma. A nurse is caring for a client who is hospitalized and asks to review his medical record. pdf from RNSG 2363 at San Antonio College. Chapter 4 Foundations of Nursing Practice Review Questions with Answers and Rationales Questions Note: Thousands of additional practice questions are available on the enclosed companion CD. B) Persistent coughing may develop. The Apgar Score. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. Identify. 0 Module: Teaching Prenatal and Newborn Care Individual. Their steadfast determination ensures efficient and quality patient care, as well as safety. The Apgar test is usually given to your baby twice: once at 1 minute after birth, and again at 5 minutes after birth. This badge card will fit perfectly on your. Since 1997, allnurses is trusted by nurses around the globe. Identify the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth: Heart Rate: 90/min Slow, weak cry Well-flexed extremities Cry with suctioning Acrocyanosis Enter the score in the field below and then submit. The nurse notes a displaced point of maximal impulse (PMI) and a cardiac thrill. place the unused portion in the client's medication drawer. Inspect the skin of a newborn who is receiving phototherapy. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. https://findapup. Nursing Flashcards. Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Discover powerful Microsoft Edge browser features with built-in privacy, security and productivity tools, that help save you time and money while shopping, browsing …. Which examination technique is the nurse using?. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. Question nurse toni is reviewing the handout about iv pain medications during labor with claire. Newborn rash, erythema toxicum, is a common finding in newborns …. Tap card to see definition 👆. The Audible Plus Catalog of podcasts, audiobooks, guided …. Helps you prepare job interviews and practice interview skills and techniques. The nurse knows that after giving the client 0. Apgar Scoring What Apgar score would you give the newborn in the video if the heart rate is 120 BPM? Activity: 2 Pulse: 2 Grimace: 2 Appearance: 1 Respiration: 2 I gave the baby a 9/10 because he has good flexion of his extremities, he cries when his feet are touched, his feet and hands appear a bit blue so he got a 1 in that category, and a 2 in respiratory due to his strong cry and adequate. 1 credit (2 credits for Prime members), good for any premium selection titles you like—yours to keep. Start studying Real Life 3. 8t sel premium the walking dead part 2 prs se, once standard 245 review nov 5 2015 meteor shower rapture michael allen harrison white warts around anus free download mp3 dj sumantri 1536p wallpaper non biaza zoos wirel project weobley to hereford bus meaning of name ridham mill basin car service 11234 motor market roma. Identify the score Toni should assign to a newborn who has the following findings at 1 minute after birth: HR: 90BPM slow, weak cry well-flexed extremities Cry with suctioning Acrocyanosis Enter the score in the field below and then submit. Cookies are currently enabled to maximize your TeePublic experience. The nurse knows that after giving the client 0. "I'm sorry, you do not have right to read your chart. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. It is taken at one minute and …. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. The nurse knows that the results of a PPD will be considered positive if induration measures at least: A registered nurse works on the medical/surgical unit. Since 1997, allnurses is trusted by nurses around the globe. In review, the two common heart sounds are S1 and S2. This is a private class. -Assists in stabilization of the heart rate. Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. The nurse notes a displaced point of maximal impulse (PMI) and a cardiac thrill. A patient is admitted with a broken hip. The Audible Plus Catalog of podcasts, audiobooks, guided …. After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may have an iron deficiency. 0 Module: Teaching Prenatal and Newborn Care Individual. The nursing process (assessment, analysis, planning, implementation, and evaluation) Caring Communication and documentation Teaching and learning The following scenarios illustrate how NCLEX items combine integrated processes and client need categories. This badge card will fit perfectly on your. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. Per the patient's history, he complains of night sweats. "I'm sorry, you do not have right to read your chart. Opioid analgesics should not be given within 1 to 4 hr of birth. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Identify the score Toni should assign to a newborn who has the following findings at …. The nurse notes a displaced point of maximal impulse (PMI) and a cardiac thrill. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. The American Health Council’s “Nurses to Watch” are truly a cut above the rest. Nurse Toni Is Reviewing The Handout About Iv Pain. Nursing Flashcards. The charge nurse is making assignments on a medical–surgical unit. 005 Infection - 50 cards. Identify the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. Jan 08, 2020 · Cyber iaf exam 2017 blue cross blue shield fee schedule 6x nvidia 1070 zcash Xnxnn 2017 video Google search for coding incision drainage Medical plexers Medial patellofemoral ligament tear icd10 Lucas kanade optical flow python Mortal kombat karnage full game Phimset loan luan Saints row 2 cheats ps3 Donnie swaggart wikipedia Ams cherish feed. 0 Module: Teaching Prenatal and Newborn Care Individual. Per the patient's history, he complains of night sweats. Upon assessment, the nurse notes the patient is coughing and is running a lowgrade fever. Identify the score nurse Toni should assign to a newborn who has the …. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. allnurses is a Nursing Career & Support site. Make sure this fitsby entering your model number. b) Increase rate of IV fluids. Tap card to see definition 👆. 0-12 months milestones gross motor skills - 12 cards. Identify the score Toni should assign to a newborn who has the following findings at …. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress. Respiratory rate of 20–28 per minute. Shop Akame of the Demon Sword Murasame akame ga kill sweatshirts designed by wearsimple as well as other akame ga kill merchandise at TeePublic. Identify. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. Obtain the weight of a newborn who is receiving formula. Identify the score Toni should assign to a newborn who has the following findings at 1 minute after birth: HR: 90BPM slow, weak cry well-flexed extremities Cry with suctioning Acrocyanosis Enter the score in the field below and then submit. Per the patient's history, he complains of night sweats. Nursing Flashcards. Report Created on: 7/22/2021 03:14 PM EDT REP_RSIndv_ModuleReport_1_0 Page 2 of 7 REP_RSIndv_ModuleReport_1_0 Page 2 of 7. ID the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. A patient is admitted with a broken hip. The presence of conjunctival hemorrhages. Optimal Decision Scenario The nurses are reviewing Apgar scoring. Apgar Scoring What Apgar score would you give the newborn in the video if the heart rate is 120 BPM? Activity: 2 Pulse: 2 Grimace: 2 Appearance: 1 Respiration: 2 I gave the baby a 9/10 because he has good flexion of his extremities, he cries when his feet are touched, his feet and hands appear a bit blue so he got a 1 in that category, and a 2 in respiratory due to his strong cry and adequate. Cookies are currently enabled to maximize your TeePublic experience. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. Report Created on: 7/22/2021 03:14 PM EDT REP_RSIndv_ModuleReport_1_0 Page 2 of 7 REP_RSIndv_ModuleReport_1_0 Page 2 of 7. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. The nursing process (assessment, analysis, planning, implementation, and evaluation) Caring Communication and documentation Teaching and learning The following scenarios illustrate how NCLEX items combine integrated processes and client need categories. 001 Introduction to Pathophysiology - 65 cards. Question 18. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. The nurse, 49, had been working at the Kendall Crescent Health Centre, in north Oxford, for a few hours when she found hundreds of emails dating back more than six months, many of them urgent, that had apparently not been dealt with by Dr Mark Huckstep, the practice’s sole GP partner. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. With 55 billion matches to date, Tinder® is the world's most popular dating app, making it the place to meet new people. Free essays, homework help, flashcards, research papers, book reports, term papers, history, science, politics. The nurse knows that after giving the client 0. It is taken at one minute and …. ID the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. Opioid analgesics should not be given within 1 to 4 hr of birth. The American Health Council’s “Nurses to Watch” are truly a cut above the rest. The appropriate response by the nurse is A. THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL SATURDAY, MAY SEVENTEENTH AND SUNDAY, MAY EIGHTEENTH TWO THOUSAND THREE 1 Digitized by the Internet Archive in 2013. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. Respiratory rate of 20–28 per minute. newborn glucose levels by decreasing the newborn ' s use of glycogen stores to maintain normothermia. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. What should the nurse do first? a) Review the patient’s preoperative vital signs. Optimal Decision Scenario The nurses are reviewing Apgar scoring. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. The Apgar Score. Nurse Toni is reviewing the handout about IV pain medications during labor with Claire. The American Rescue Plan directs the $1,400 direct payments to individuals earning up to$75,000, but cuts off eligibility for single people earning more than …. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. The American Health Council’s “Nurses to Watch” are truly a cut above the rest. Professional academic writers. A patient is admitted with a broken hip. "We'll give you a copy of your records when you are discharged. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Start studying Real Life 3. APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns. "You will need permission from the hospital administration to review your chart. The nurse should identify that which of the following factors can affect the Apgar score?. 0 Module: Teaching Prenatal and Newborn Care Individual. A nurse is caring for a client who is hospitalized and asks to review his medical record. Make sure this fitsby entering your model number. A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Denotes alternate format question. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. La parola italiana libro deriva dal latino liber. Identify the score nurse Toni should assign to NB who has the following findings at 1 minute after birth: HR- 90 bpm Slow, weak cry Well-flexed extremities Cry with suctioning Acrocyanosis Enter the score: 7 Apgar score. They each are made up of two distinctly separate sounds of two valves closing in unison. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. A 25-year-old woman comes to the clinic because of a chronic, nonproductive cough. After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may have an iron deficiency. Il vocabolo originariamente significava anche "corteccia", ma visto che era un materiale usato per scrivere testi (in libro scribuntur litterae, Plauto), in seguito per estensione la parola ha assunto il significato di "opera letteraria". So concludes a recently published paper in American Economic Review. APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns. Rationale Opioid analgesics cross the placenta and can cause respiratory depression in the newborn. Question Nurse Toni is reviewing Apgar scoring with charge. A nurse is examining an elderly patient who presents to the emergency department complaining of shortness of breath. Which of the following information should Nurse Toni include?. Apgar Scoring What Apgar score would you give the newborn in the video if the heart rate is 120 BPM? Activity: 2 Pulse: 2 Grimace: 2 Appearance: 1 Respiration: 2 I gave the baby a 9/10 because he has good flexion of his extremities, he cries when his feet are touched, his feet and hands appear a bit blue so he got a 1 in that category, and a 2 in respiratory due to his strong cry and adequate. Cookies are currently enabled to maximize your TeePublic experience. 8t sel premium the walking dead part 2 prs se, once standard 245 review nov 5 2015 meteor shower rapture michael allen harrison white warts around anus free download mp3 dj sumantri 1536p wallpaper non biaza zoos wirel project weobley to hereford bus meaning of name ridham mill basin car service 11234 motor market roma. Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. "We'll give you a copy of your records when you are discharged. The American Health Council’s “Nurses to Watch” are truly a cut above the rest. newborn glucose levels by decreasing the newborn ’ s use of glycogen stores to maintain normothermia. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. https://findapup. A nurse is caring for a client who is hospitalized and asks to review his medical record. What should the nurse do first? a) Review the patient’s preoperative vital signs. allnurses is a Nursing Career & Support site. "We'll give you a copy of your records when you are discharged. b) Increase rate of IV fluids. Jan 08, 2020 · Cyber iaf exam 2017 blue cross blue shield fee schedule 6x nvidia 1070 zcash Xnxnn 2017 video Google search for coding incision drainage Medical plexers Medial patellofemoral ligament tear icd10 Lucas kanade optical flow python Mortal kombat karnage full game Phimset loan luan Saints row 2 cheats ps3 Donnie swaggart wikipedia Ams cherish feed. Question 18-Health Promotion and Maintenance Practice Test for the NCLEX-RN® Exam. RATIONALES: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. Their steadfast determination ensures efficient and quality patient care, as well as safety. The medication is available in a pre filled syringe does of 10 mg/mL. The nurses assessment reveals that she has a history of asthma. 005 Infection - 50 cards. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. pdf from RNSG 2363 at San Antonio College. Which of the following information should Nurse Toni include? Click card to see definition 👆. "You will need permission from the hospital administration to review your chart. Identify the score Toni should assign to a newborn who has the following findings at 1 minute after birth: HR: 90BPM slow, weak cry well-flexed extremities Cry with suctioning Acrocyanosis Enter the score in the field below and then submit. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). A nurse is caring for a client who is hospitalized and asks to review his medical record. The charge nurse is making assignments on a medical–surgical unit. A patient is admitted with a broken hip. Start studying Real Life 3. Scenario The nurses are reviewing Apgar scoring. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). The APGAR Scoring System was developed by Dr. Cyanosis of the hands and feet. Question 18-Health Promotion and Maintenance Practice Test for the NCLEX-RN® Exam. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. 1 credit (2 credits for Prime members), good for any premium selection titles you like—yours to keep. Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. 0 Module: Teaching Prenatal and Newborn Care Individual. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. Etimologia del termine. Professional academic writers. The Apgar Score. 0 RN Maternal Newborn Teaching Prenatal and Newborn Care. pdf from NR 452 at Chamberlain College of Nursing. The nurse knows that after giving the client 0. The American Rescue Plan directs the $1,400 direct payments to individuals earning up to$75,000, but cuts off eligibility for single people earning more than …. THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL SATURDAY, MAY SEVENTEENTH AND SUNDAY, MAY EIGHTEENTH TWO THOUSAND THREE 1 Digitized by the Internet Archive in 2013. This is a private class. Module Report Tutorial: Real Life RN Maternal Newborn 3. b) Increase rate of IV fluids. Report Created on: 7/22/2021 03:14 PM EDT REP_RSIndv_ModuleReport_1_0 Page 2 of 7 REP_RSIndv_ModuleReport_1_0 Page 2 of 7. When assessing the patient for heart sounds, the nurse must first obtain a patient history; inspection, palpation and possibly percussion will also usually be performed before you begin to auscultate. "You will need permission from the hospital administration to review your chart. Identify the score nurse Toni should assign to a newborn who has the …. A patient is admitted with a broken hip. Free essays, homework help, flashcards, research papers, book reports, term papers, history, science, politics. https://findapup. Apgar Scoring What Apgar score would you give the newborn in the video if the heart rate is 120 BPM? Activity: 2 Pulse: 2 Grimace: 2 Appearance: 1 Respiration: 2 I …. com, INC, 7900 International Drive #300, Bloomington MN 55425 1-612-816-8773. d) Notify the physician. Optimal Decision Scenario The nurses are reviewing Apgar scoring Question Nurse from NURSING NURS 306 at West Coast University. With 55 billion matches to date, Tinder® is the world's most popular dating app, making it the place to meet new people. View TEACHINANDNEWBORNATIREALLIFE. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. newborn glucose levels by decreasing the newborn ' s use of glycogen stores to maintain normothermia. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress. Inspect the skin of a newborn who is receiving phototherapy. 0 Module: Teaching Prenatal and Newborn Care Individual. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Our global writing staff includes experienced ENL & ESL academic writers in a variety of disciplines. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. For example, you get this test question: The nurse is assessing a newborn that has a heart rate 198, a strong cry, which resists when touched and has blue hands and feet. Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Upon assessment, the nurse notes the patient is coughing and is running a lowgrade fever. From small town clinics to major metropolitan medical centers, these nurses and educators exhibit the qualities that define the benchmark for their specialty. ID the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. Free book How Emotions Are Made: The …. A patient is admitted with a broken hip. The nurses assessment reveals that she has a history of asthma. Identify the score Toni should assign to a newborn who has the following findings at …. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. Newborn rash, erythema toxicum, is a common finding in newborns, and it is not prevented by skin-to-skin contact. Which of the following information should Nurse Toni include?. This lets us find the most appropriate writer for any type of assignment. Question nurse toni is reviewing the handout about iv pain medications during labor with claire. The nurse knows that after giving the client 0. "We'll give you a copy of your records when you are discharged. A client has requested pain medication. Nursing Flashcards. A nurse is caring for a client who is hospitalized and asks to review his medical record. DON'T BE CAUGHT OFF GUARD - The perfect APGAR Newborn Assessment information when you need a reminder on the spot. The Apgar test is usually given to your baby twice: once at 1 minute after birth, and again at 5 minutes after birth. Our members represent more than 60 professional nursing specialties. The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97. View teaching prenal and newborn. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. The nurses assessment reveals that she has a history of asthma. Identify the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. newborn glucose levels by decreasing the newborn ' s use of glycogen stores to maintain normothermia. APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns. A patient is admitted with a broken hip. Tap card to see definition 👆. Cookies are currently enabled to maximize your TeePublic experience. The appropriate response by the nurse is A. 2°F oral, blood pressure 84/50. Dextromethorphan, (Robitussin) is prescribed for her. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. They each are made up of two distinctly separate sounds of two valves closing in unison. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. c) Assess for bleeding. Identify the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth: Heart Rate: 90/min Slow, weak cry Well-flexed extremities Cry with suctioning Acrocyanosis Enter the score in the field below and then submit. Question 18-Health Promotion and Maintenance Practice Test for the NCLEX-RN® Exam. A nurse is caring for a client who is hospitalized and asks to review his medical record. The medication is available in a pre filled syringe does of 10 mg/mL. "I'm sorry, you do not have right to read your chart. Erythema toxicum parent handout keyword after analyzing the system lists the list of keywords related and the list of websites with related content, in addition you can see which keywords most interested customers on the this website. Cyanosis of the hands and feet. Optimal Decision Scenario The nurses are reviewing Apgar scoring. allnurses is a Nursing Career & Support site. Module Report Tutorial: Real Life RN Maternal Newborn 3. The most likely reason for this score is: The mottled appearance of the trunk. Question 18. 002 Fluid, Electrolyte and Acid-Base Imbalances - 37 cards. View teaching prenal and newborn. Since 1997, allnurses is trusted by nurses around the globe. 001 Introduction to Pathophysiology - 65 cards. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. Following electroconvulsive therapy, the nurse should monitor the client's vital signs every 15 minutes for the 1st hour. "We'll give you a copy of your records when you are discharged. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. This lets us find the most appropriate writer for any type of assignment. They each are made up of two distinctly separate sounds of two valves closing in unison. Heart Rate: 90/min Slow, weak cry Well-flexed extremities Cry with suctioning Acrocyanosis. ID the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. DON'T BE CAUGHT OFF GUARD - The perfect APGAR Newborn Assessment information when you need a reminder on the spot. A nurse is caring for a client who is hospitalized and asks to review his medical record. View Report (85). Question Nurse Toni is reviewing Apgar scoring with charge. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. Which examination technique is the nurse using?. c) Assess for bleeding. Virginia APGAR as a method of assessing the newborn's adjustment to extrauterine life. La parola italiana libro deriva dal latino liber. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. Which technique is correct during the assessment? The nurse should examine the tender area last. A nurse is caring for a client who is hospitalized and asks to review his medical record. Inspect the skin of a newborn who is receiving phototherapy. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. Report Created on: 7/22/2021 03:14 PM EDT REP_RSIndv_ModuleReport_1_0 Page 2 of 7 REP_RSIndv_ModuleReport_1_0 Page 2 of 7. Il vocabolo originariamente significava anche "corteccia", ma visto che era un materiale usato per scrivere testi (in libro scribuntur litterae, Plauto), in seguito per estensione la parola ha assunto il significato di "opera letteraria". After completing a diet assessment on a 30-year-old woman, the nurse suspects that she may have an iron deficiency. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Denotes alternate format question. Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. DON'T BE CAUGHT OFF GUARD - The perfect APGAR Newborn Assessment information when you need a reminder on the spot. 8t sel premium the walking dead part 2 prs se, once standard 245 review nov 5 2015 meteor shower rapture michael allen harrison white warts around anus free download mp3 dj sumantri 1536p wallpaper non biaza zoos wirel project weobley to hereford bus meaning of name ridham mill basin car service 11234 motor market roma. The nurse knows that after giving the client 0. allnurses is a Nursing Career & Support site. View TEACHINANDNEWBORNATIREALLIFE. The American Health Council’s “Nurses to Watch” are truly a cut above the rest. pdf from NR 452 at Chamberlain College of Nursing. The nurse should position the client on his side after the procedure to reduce the risk of aspiration. 0 Module: Teaching Prenatal and Newborn Care Individual. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. allnurses is a Nursing Career & Support site. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. Module Report Tutorial: Real Life RN Maternal Newborn 3. The nurse should identify that which of the following factors can affect the Apgar score?. Identify the score Toni should assign to a newborn who has the following findings at …. D) Secretions may be retained. Erythema toxicum parent handout keyword after analyzing the system lists the list of keywords related and the list of websites with related content, in addition you can see which keywords most interested customers on the this website. Which of the following is an appropriate task for the AP? O O O O Show a new mother how to change the newborn's diaper. 0 RN Maternal Newborn Teaching Prenatal and Newborn Care. https://findapup. To android jetta 1. -Helps with thermoregulation. Shop Akame of the Demon Sword Murasame akame ga kill sweatshirts designed by wearsimple as well as other akame ga kill merchandise at TeePublic. newborn glucose levels by decreasing the newborn ' s use of glycogen stores to maintain normothermia. The Apgar Score. Virginia APGAR as a method of assessing the newborn's adjustment to extrauterine life. A nurse is caring for a client who is hospitalized and asks to review his medical record. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Nurse Toni is reviewing the benefits of skin-to-skin contact for a newborn with Claire and Kyle. Helps you prepare job interviews and practice interview skills and techniques. The nurses assessment reveals that she has a history of asthma. The most likely reason for this score is: The mottled appearance of the trunk. 5 mL, the appropriate action is to A. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns. Start studying Real Life 3. Rarely, if there are concerns …. Identify. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. Report Created on: 7/22/2021 03:14 PM EDT REP_RSIndv_ModuleReport_1_0 Page 2 of 7 REP_RSIndv_ModuleReport_1_0 Page 2 of 7. Nurse Toni is reviewing the handout about IV pain medications during labor with Claire. d) Notify the physician. Optimal Decision Scenario The nurses are reviewing Apgar scoring. 001 Introduction to Pathophysiology - 65 cards. Il vocabolo originariamente significava anche "corteccia", ma visto che era un materiale usato per scrivere testi (in libro scribuntur litterae, Plauto), in seguito per estensione la parola ha assunto il significato di "opera letteraria". pdf from RNSG 2363 at San Antonio College. The appropriate response by the nurse is A. D) Secretions may be retained. Read and download Lisa Feldman Barrett book How Emotions Are Made: The Secret Life of the Brain in PDF, EPub, Mobi, Kindle online. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). A nurse is discussing Apgar scoring with a newly licensed nurse. "We'll give you a copy of your records when you are discharged. com/advert/le-casino-cafe-de-paris-monte-carlo-bres-everlasting-beauty/. Upon assessment, the nurse notes the patient is coughing and is running a lowgrade fever. 2°F oral, blood pressure 84/50. Identify. Professional academic writers. ID the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. What should the nurse do first? a) Review the patient’s preoperative vital signs. Cookies are currently enabled to maximize your TeePublic experience. Erythema toxicum parent handout keyword after analyzing the system lists the list of keywords related and the list of websites with related content, in addition you can see which keywords most interested customers on the this website. Nurse Toni Is Reviewing The Handout About Iv Pain. -Assists in stabilization of the heart rate. b) Increase rate of IV fluids. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL SATURDAY, MAY SEVENTEENTH AND SUNDAY, MAY EIGHTEENTH TWO THOUSAND THREE 1 Digitized by the Internet Archive in 2013. B) Persistent coughing may develop. A nurse is caring for a client who is hospitalized and asks to review his medical record. A nurse is examining an elderly patient who presents to the emergency department complaining of shortness of breath. 5 mL, the appropriate action is to A. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. A 5-month-old infant is admitted to the ER with a temperature of 6°F and irritability. The appropriate response by the nurse is A. To android jetta 1. Scenario The nurses are reviewing Apgar scoring. Identify the score nurse Toni should assign to a newborn who has the …. Read and download Lisa Feldman Barrett book How Emotions Are Made: The Secret Life of the Brain in PDF, EPub, Mobi, Kindle online. Helps you prepare job interviews and practice interview skills and techniques. The nurse notes that morphine 5 mg is ordered subcutaneously q3 to 4 hr. Question 18. B) Persistent coughing may develop. The Apgar Score. This badge card will fit perfectly on your. The nurse will question this order because: A) Serotonin syndrome may result. RATIONALES: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. Module Report Tutorial: Real Life RN Maternal Newborn 3. https://findapup. Opioid analgesics should not be given within 1 to 4 hr of birth. Il vocabolo originariamente significava anche "corteccia", ma visto che era un materiale usato per scrivere testi (in libro scribuntur litterae, Plauto), in seguito per estensione la parola ha assunto il significato di "opera letteraria". A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP). Their steadfast determination ensures efficient and quality patient care, as well as safety. Question nurse toni is reviewing the handout about iv pain medications during labor with claire. 001 Introduction to Pathophysiology - 65 cards. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Jan 08, 2020 · Cyber iaf exam 2017 blue cross blue shield fee schedule 6x nvidia 1070 zcash Xnxnn 2017 video Google search for coding incision drainage Medical plexers Medial patellofemoral ligament tear icd10 Lucas kanade optical flow python Mortal kombat karnage full game Phimset loan luan Saints row 2 cheats ps3 Donnie swaggart wikipedia Ams cherish feed. When assessing the patient for heart sounds, the nurse must first obtain a patient history; inspection, palpation and possibly percussion will also usually be performed before you begin to auscultate. A 25-year-old woman comes to the clinic because of a chronic, nonproductive cough. What should the nurse do first? a) Review the patient’s preoperative vital signs. ID the score nurse Toni should assign to a newborn who has the following findings …. The nurse should identify that which of the following factors can affect the Apgar score?. Identify. Free essays, homework help, flashcards, research papers, book reports, term papers, history, science, politics. The nursing process (assessment, analysis, planning, implementation, and evaluation) Caring Communication and documentation Teaching and learning The following scenarios illustrate how NCLEX items combine integrated processes and client need categories. The nurse knows that after giving the client 0. 0 Module: Teaching Prenatal and Newborn Care …. Our global writing staff includes experienced ENL & ESL academic writers in a variety of disciplines. The 5-minute Apgar of a baby delivered by C-section is recorded as 9. Question Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. B) Persistent coughing may develop. 004 Inflammation and Healing - 49 cards. Rarely, if there are concerns …. Nurse Toni is reviewing APGAR scoring with charge nurse Sandra. View teaching prenal and newborn. Our mission is to Empower, Unite, and Advance every nurse, student, and educator. The Apgar test is usually given to your baby twice: once at 1 minute after birth, and again at 5 minutes after birth. Scenario The nurses are reviewing Apgar scoring. Since 1997, allnurses is trusted by nurses around the globe. Nurse Toni Is Reviewing The Handout About Iv Pain. Apgar Scoring What Apgar score would you give the newborn in the video if the heart rate is 120 BPM? Activity: 2 Pulse: 2 Grimace: 2 Appearance: 1 Respiration: 2 I …. Shop Akame of the Demon Sword Murasame akame ga kill sweatshirts designed by wearsimple as well as other akame ga kill merchandise at TeePublic. Which examination technique is the nurse using?. D) Secretions may be retained. With 55 billion matches to date, Tinder® is the world's most popular dating app, making it the place to meet new people. A 25-year-old woman comes to the clinic because of a chronic, nonproductive cough. Dextromethorphan, (Robitussin) is prescribed for her. APGAR is a scoring technique that helps medical professionals, especially nurses, to do a quick head-to-toe assessment of newborns. 8t sel premium the walking dead part 2 prs se, once standard 245 review nov 5 2015 meteor shower rapture michael allen harrison white warts around anus free download mp3 dj sumantri 1536p wallpaper non biaza zoos wirel project weobley to hereford bus meaning of name ridham mill basin car service 11234 motor market roma. Our global writing staff includes experienced ENL & ESL academic writers in a variety of disciplines. com, INC, 7900 International Drive #300, Bloomington MN 55425 1-612-816-8773. A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Rarely, if there are concerns …. "You will need permission from the hospital administration to review your chart. Apgar Scoring What Apgar score would you give the newborn in the video if the heart rate is 120 BPM? Activity: 2 Pulse: 2 Grimace: 2 Appearance: 1 Respiration: 2 I gave the baby a 9/10 because he has good flexion of his extremities, he cries when his feet are touched, his feet and hands appear a bit blue so he got a 1 in that category, and a 2 in respiratory due to his strong cry and adequate. "I'm sorry, you do not have the right to read your chart. Job interview questions and sample answers list, tips, guide and advice. D) Secretions may be retained. Nurse Toni is reviewing the handout about IV pain medications during labor with Claire. DON'T BE CAUGHT OFF GUARD - The perfect APGAR Newborn Assessment information when you need a reminder on the spot. View teaching prenal and newborn. THE ULTIMATE APGAR NEWBORN ASSESSMENT REFERENCE! That difficult to remember APGAR Newborn Assessment Information will be at your fingertips with this convenient and easy to use badge card. newborn glucose levels by decreasing the newborn ' s use of glycogen stores to maintain normothermia. 0 Module: Teaching Prenatal and Newborn Care …. Read and download Lisa Feldman Barrett book How Emotions Are Made: The Secret Life of the Brain in PDF, EPub, Mobi, Kindle online. Which technique is correct during the assessment? The nurse should examine the tender area last. View TEACHINANDNEWBORNATIREALLIFE. Optimal Decision Scenario The nurses are reviewing Apgar scoring Question Nurse from ENGLISH 204 at Alabama A&M University. La parola italiana libro deriva dal latino liber. -Helps with thermoregulation. The nursing process (assessment, analysis, planning, implementation, and evaluation) Caring Communication and documentation Teaching and learning The following scenarios illustrate how NCLEX items combine integrated processes and client need categories. Free book How Emotions Are Made: The …. The Audible Plus Catalog of podcasts, audiobooks, guided …. Il vocabolo originariamente significava anche "corteccia", ma visto che era un materiale usato per scrivere testi (in libro scribuntur litterae, Plauto), in seguito per estensione la parola ha assunto il significato di "opera letteraria". 0 RN Maternal Newborn Teaching Prenatal and Newborn Care. The American Health Council’s “Nurses to Watch” are truly a cut above the rest. Nurse Toni is reviewing Apgar scoring with charge nurse Sandra. com/advert/le-casino-cafe-de-paris-monte-carlo-bres-everlasting-beauty/. A nurse is caring for a client who is hospitalized and asks to review his medical record. A 25-year-old woman comes to the clinic because of a chronic, nonproductive cough. Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. ID the score nurse Toni should assign to a newborn who has the following findings at 1 minute after birth. In your Google Account, you can see and manage your info, activity, security options, and privacy preferences to make Google work better for you. com, INC, 7900 International Drive #300, Bloomington MN 55425 1-612-816-8773. Report Created on: 7/22/2021 03:14 PM EDT REP_RSIndv_ModuleReport_1_0 Page 2 of 7 REP_RSIndv_ModuleReport_1_0 Page 2 of 7. It is taken at one minute and …. So concludes a recently published paper in American Economic Review.

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Now freeze, and do not bother with or without. She did not answer, and did not interfere with the subsequent pulling off of her remaining clothes. Surprisingly quickly, the girl was mentally broken, and completely subordinated to my will. I raised her to her feet, ordered her to turn around, demonstrate the dignity of my body.

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