What is the first action the nurse should take after noting a systolic murmur during a head-to-toe assessment?

Determining whether the systolic murmur is a new finding is crucial for assessing the client’s cardiac status effectively. By checking the chart for any previous documentation of a murmur, the nurse can discern whether this is a new development or a known condition. This knowledge helps guide subsequent actions, such as whether immediate care or monitoring is necessary.

If the murmur is indeed new, it may indicate an evolving cardiac condition that requires prompt attention and potentially notifying the healthcare provider. Conversely, if it's an existing finding with documentation, the nurse can take appropriate steps to continue monitoring without immediate alarm. This foundational information is essential for establishing a comprehensive plan of care and ensuring the client’s safety.

Taking this initial step aids in organizing the nursing intervention, providing a clearer picture of the patient’s history, and facilitating communication with the healthcare team.