A nurse is caring for a client who has an indwelling urinary catheter.

The nurse notes that sediment is present in the urine.

Which of the following actions should the nurse take to obtain a sterile urine specimen?

This is because at 12 weeks of gestation, the uterus is still low in the pelvis and the fetal heart tones are best audible through the fetal back, which is usually located just above the symphysis pubis. The fetal heart rate at this stage is normally between 120 and 180 beats per minute.
Choice B is wrong because measuring the fundal height is not necessary to determine the placement of the ultrasound stethoscope at 12 weeks of gestation. The fundal height is usually measured from 20 weeks of gestation onwards to assess fetal growth and estimate gestational age.
Choice C is wrong because placing the client in a side-lying position prior to assessing the fetal heart rate is not required at 12 weeks of gestation. This position may be helpful later in pregnancy to improve maternal blood flow and oxygen delivery to the fetus, especially if there are signs of fetal distress or hypoxia.
Choice D is wrong because performing Leopold maneuvers prior to auscultating the fetal heart rate is not appropriate at 12 weeks of gestation.
Leopold maneuvers are a series of four steps to palpate the abdomen and determine the fetal position, presentation, lie, and engagement. They are usually performed after 24 weeks of gestation when the fetus is large enough to be felt through the abdominal wall.

Valsartan is a medication that lowers blood pressure by blocking the action of angiotensin II, a hormone that causes blood vessels to constrict. By dilating the blood vessels, valsartan reduces the pressure in the arteries and improves blood flow to the organs. However, if the dose of valsartan is too high, it can cause excessive lowering of blood pressure, which can lead to symptoms such as dizziness, fainting, blurred vision, or nausea. This is especially likely when the client changes position from lying or sitting to standing, which is called orthostatic hypotension. Therefore, the nurse should monitor the client’s blood pressure and pulse in different positions and report any significant changes to the provider. The nurse should also instruct the client to rise slowly from a lying or sitting position and to avoid driving or operating machinery until the effects of the medication wear off.

Choice A is wrong because monitoring the client’s urine output is not a priority action for a client who received an overdose of valsartan.

Valsartan does not have a direct effect on urine output, although it may affect kidney function in some cases. The nurse should monitor the client’s serum creatinine and blood urea nitrogen levels to assess kidney function, but this is not as urgent as evaluating the client for orthostatic hypotension.

Choice B is wrong because checking the client for nasal congestion is not a priority action for a client who received an overdose of valsartan.

Nasal congestion is not a common or serious side effect of valsartan. It is more likely to occur with other types of blood pressure medications, such as angiotensin-converting enzyme (ACE) inhibitors or beta blockers.

Choice D is wrong because obtaining the client’s laboratory results is not a priority action for a client who received an overdose of valsartan.

Laboratory results may provide useful information about the client’s electrolyte levels, kidney function, liver function, or blood counts, but they are not as important as assessing the client’s vital signs and symptoms of hypotension. The nurse should obtain the laboratory results after stabilizing the client’s blood pressure and ensuring adequate perfusion to the organs.