A Soft Murmur and Breathlessness at Thirty Weeks: A Cardiovascular and Respiratory Assessment of a Pregnant Woman, Sorting Normal Physiology From Warning Signs
[Student Name]
University of Phoenix
NSG/502: Pathophysiology, Assessment Variables and Pharmacology II
Week 3 Assignment
[Instructor Name]
[Date]
The patient and all findings are a composite written for a model paper.
Identifying Data
Ms. G. H., 32, gravida 2, para 1, at 30 weeks and 2 days of a singleton pregnancy, seen for a routine prenatal visit. Ms. H. gave her own history, clearly and consistently.
Subjective Data
She reports being "short of breath climbing stairs" for the past month and feeling she "can't get a deep enough breath" at times, even sitting, without cough, wheeze or chest pain. She sleeps on two pillows for comfort because of heartburn. She notices her heart "beating harder" at times and occasional brief lightheadedness on standing quickly. Her ankles swell by evening and improve overnight. She denies palpitations lasting minutes, fainting, calf pain, headache, visual changes or swelling of the face or hands. No history of heart disease, asthma or blood clots. Her previous pregnancy was uncomplicated. She takes a prenatal vitamin.
Objective Findings: Vital Signs
Blood pressure 108/64 mm Hg seated, right arm; heart rate 92 beats per minute, regular; respiratory rate 18 breaths per minute; oxygen saturation 98% on room air; temperature 36.8 degrees Celsius. Blood pressure at her first-trimester visit was 116/72 mm Hg, and heart rate 76.
Objective Findings: Cardiovascular
Jugular venous pressure not elevated at 30 degrees. Carotid upstrokes brisk, no bruits. Apical impulse palpable in the fourth intercostal space, just lateral to the left midclavicular line, not sustained. S1 normal and slightly louder than expected; S2 normal with physiological splitting. A soft midsystolic murmur, grade 2 of 6, loudest over the second left intercostal space beside the sternum, not radiating, with a normal second heart sound. No diastolic murmur. No S3 or S4 appreciated. Peripheral pulses 2+ and symmetric. Trace pitting edema to the ankles bilaterally; calves soft and nontender, without asymmetry.
Objective Findings: Respiratory
Chest symmetric; subcostal angle widened. Respirations unlabored at rest. Breath sounds vesicular and equal bilaterally, no crackles or wheezes. Diaphragmatic excursion reduced, estimated at 3 cm.
Interpretation: Cardiovascular Findings
Pregnancy changes the cardiovascular system more than almost any other period of life. Blood volume rises by about 40 to 50 percent, cardiac output increases by 30 to 50 percent, largely through increased stroke volume and a heart rate 10 to 20 beats per minute higher, and systemic vascular resistance falls, lowering blood pressure in the second trimester before it rises again toward term (Sanghavi & Rutherford, 2014).
Against that background, most of Ms. H.'s findings are expected. Her heart rate of 92, 16 beats above her first-trimester value, fits the normal rise. Her blood pressure is slightly lower than early pregnancy, as expected with falling vascular resistance. The apical impulse is displaced upward and outward because the enlarging uterus raises the diaphragm and shifts the heart. A louder S1 and a soft systolic murmur at the left upper sternal border reflect increased flow across normal valves; such flow murmurs are heard in most pregnant women. Lightheadedness on standing reflects lower vascular resistance and pooling of blood in the legs. Ankle edema that resolves overnight comes from increased venous pressure in the legs and lower plasma oncotic pressure (Sanghavi & Rutherford, 2014).
What would change this interpretation is not the presence of a murmur but its character or its company. A diastolic murmur, a murmur louder than grade 3, a murmur with a thrill, a sustained or markedly displaced apical impulse, an S3 heard clearly with symptoms, a raised jugular venous pressure or pulmonary crackles would all suggest structural heart disease or cardiomyopathy and need echocardiography. So would edema of the face or hands, which with a raised blood pressure would suggest preeclampsia, or unilateral leg swelling with calf tenderness, which would suggest deep vein thrombosis. Ms. H. has none of these.
Interpretation: Respiratory Findings
The respiratory system also adapts. Progesterone increases the sensitivity of the respiratory center to carbon dioxide, raising minute ventilation mostly through deeper breaths, which many women experience as breathlessness even at rest. The growing uterus raises the diaphragm by about 4 cm, and the rib cage widens to compensate, which is why her subcostal angle is wider and her diaphragmatic excursion appears reduced (LoMauro & Aliverti, 2015). Her normal respiratory rate, clear breath sounds and normal oxygen saturation support physiological dyspnea of pregnancy.
Warning signs would be dyspnea that comes on suddenly, breathlessness with a fast respiratory rate or low oxygen saturation, pleuritic chest pain, cough with blood or crackles on examination. Pregnancy raises the risk of pulmonary embolism, and new or worsening breathlessness with any of these features needs urgent evaluation.
Technique Adaptations in Late Pregnancy
Examining a woman at 30 weeks requires adjustments. Lying flat on her back can compress the inferior vena cava under the weight of the uterus, lowering venous return and blood pressure and making her lightheaded, so the examination was performed with her seated and then in a left lateral tilt rather than supine. Blood pressure was measured seated with her arm at heart level, since readings taken lying on the left side can be falsely low in the upper arm. The apical impulse was palpated with her leaning slightly to the left, which makes the displaced impulse easier to find. Edema was assessed at the ankles and shins and also on the hands and face, because swelling in the upper body has a different meaning in pregnancy. Finally, the nurse asked about symptoms in her own terms, such as whether she could finish a sentence while climbing stairs, which gives a more useful picture of breathlessness than a yes-or-no question.
Plan Based on Findings
No further cardiac testing is indicated at this time. Teach Ms. H. to report breathlessness at rest that is new or worsening, chest pain, palpitations lasting more than a few minutes, fainting, swelling of face or hands, severe headache, visual changes or pain and swelling in one leg. Advise rising slowly, lying on her left side and elevating her legs in the evening. Reassess at each prenatal visit, including blood pressure, edema and a brief question about breathlessness, and document the heart rate each time so a trend is visible.
Life-Span Comparison
The same findings would carry different meanings at other stages. A new systolic murmur in a 74-year-old woman would raise concern for aortic stenosis; breathlessness climbing stairs in a 60-year-old man could signal heart failure or coronary disease. In pregnancy, both findings are expected unless accompanied by warning features. The skill is matching the finding to the physiology of the person in front of the nurse (Bickley et al., 2021).
Conclusion
Ms. H.'s cardiovascular and respiratory findings at 30 weeks, a soft systolic flow murmur, a displaced apical impulse, a higher heart rate, lower blood pressure, ankle edema and breathlessness with exertion, are explained by the normal physiology of pregnancy. None of the features that would signal heart disease, preeclampsia or pulmonary embolism is present, and the plan focuses on teaching her when to seek care.
References
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
LoMauro, A., & Aliverti, A. (2015). Respiratory physiology of pregnancy: Physiology masterclass. Breathe, 11(4), 297-301. https://doi.org/10.1183/20734735.008615
Sanghavi, M., & Rutherford, J. D. (2014). Cardiovascular physiology of pregnancy. Circulation, 130(12), 1003-1008. https://doi.org/10.1161/CIRCULATIONAHA.114.009029
How this NSG 502 Week 3 example is structured
The NSG/502 description stresses physiological and developmental variables across the life span. Pregnancy is a period when normal cardiovascular and respiratory findings change sharply, so this sample documents the examination in clinical form and then interprets each finding against pregnancy physiology, separating the expected from the warning sign. Students search this week as NSG 502 Week 3, NSG502 Wk 3 or NSG/502 Wk 3; all three are the same assignment.
NSG/502 Week 3 questions, answered
What does NSG/502 Week 3 usually ask for?
Many sections cover the cardiovascular and respiratory examinations in the middle weeks, asking for a documented assessment and an interpretation that accounts for the patient's age or life stage.
Is a heart murmur normal in pregnancy?
A soft systolic flow murmur is common in pregnancy because blood volume and cardiac output rise. Diastolic murmurs, loud murmurs or murmurs with symptoms are not explained by pregnancy and need evaluation.
Why do pregnant women feel short of breath?
Progesterone increases the drive to breathe and the uterus raises the diaphragm, so many women notice breathlessness. Breathlessness at rest, with a fast heart rate or with chest pain is a warning sign.
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