# A nurse auscultates an adult client at the cardiac apex. Listen to the recording. Which finding should the nurse document?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=604457&lang=en  
> language: en  
> subject: Lifestyle Choices  
> category: HPM

## Question

A nurse auscultates an adult client at the cardiac apex. Listen to the recording. Which finding should the nurse document?

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🎧Cardiac auscultation recording

Use headphones if available. You may replay the recording.

1

An S3 gallop occurring after S2

✕

2

An irregularly irregular cardiac rhythm

✕

3

Regular S1 and S2 without an additional heart sound

✕

4

A pericardial friction rub

✕

## Explanation

The recording demonstrates a regular paired S1 and S2 pattern without an added sound. Expected documentation describes the rate or rhythm and the presence of S1 and S2 rather than assigning an unverified diagnosis.

## In-depth explanation

Quick answer
Document regular S1 and S2 without an additional heart sound.
Clinical reasoning
The paired sounds repeat at a regular interval, and no distinct third sound or scratchy rub is heard. The finding is documented directly without inferring a disease.
Audio attribution
James Heilman, MD · CC0-1.0
**Sources**
- NCBI Bookshelf — Nursing Skills: Cardiovascular Assessment

- Audio source and license record

## Key concepts

- **S1** — The first heart sound, associated with closure of the mitral and tricuspid valves at the onset of systole.
- **S2** — The second heart sound, associated with closure of the aortic and pulmonic valves at the end of systole.

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