When assessing the breath sounds of an 18-month-old who is crying, what should the nurse do?

• A. Auscultate and document breath sounds, noting that the child was crying at the time.
• B. Ask the parent to quiet the child so breath sounds can be auscultated.
• C. Document that the assessment is not available because the child is crying.
• D. Allow the child to initially play with the stethoscope, and distract during auscultation.

Answer: (A)

When assessing breath sounds in a young child, crying can alter the sounds you hear and the breathing pattern, so you should document the exact context of the exam. Auscultating now and noting that the child was crying provides accurate clinical data and helps others interpret the findings later. If you can, you may try to calm the child, but the act of auscultation should not be postponed, and the note should reflect that the assessment occurred while the child was crying. That way, the record shows both the data and the influencing factor, which is essential for proper assessment and follow-up.