A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take?

A. Peripheral pulse assessment is typically done at sites such as the radial, brachial, or carotid arteries. Palpating at the third intercostal space is not a standard site for pulse assessment and would not provide accurate heart rate or rhythm information. B. For clients with an irregular heart rate, the apical pulse provides the most accurate measurement. The nurse should auscultate at the fifth intercostal space at the midclavicular line (apical site) for a full minute to assess both rate and rhythm. This is especially important when the rhythm is irregular because peripheral pulses may be inconsistent or difficult to detect. C. While counting for 30 seconds is sometimes acceptable for regular rhythms, it is not recommended for irregular rhythms. In irregular heart rhythms, a full 60-second assessment ensures accurate detection of variability and missed beats. D. The Valsalva maneuver is a technique sometimes used to terminate certain supraventricular tachycardias, but it is not a standard assessment for measuring heart rate. Performing it without indication can be unsafe and is not part of routine evaluation for irregular heart rate.