The nurse has reviewed the Vital Signs and Nurses' Notes from 5 weeks ago.

Click to highlight the findings the nurse should report to the provider. To deselect a finding, click on the finding again.

Body System	Findings
Gastrointestinal	Client states, "I'm nauseated all the time. I vomit a few times a day, too." Client states, "I've been a little constipated, but it's not too bad." Abdomen without tenderness on palpation. Bowel sounds hypoactive. Oral mucous membranes sticky.
Genitourinary	Also reports they are urinating less and that urine is dark yellow and odorous. Clean-catch urine specimen obtained. Urine noted to be dark yellow and concentrated
Cardiovascular	Heart rate regular. No edema. Heart rate 92/min Blood pressure 102/66 mm Hg

 

Rationale for correct choices

• Gastrointestinal: Persistent nausea and frequent vomiting in early pregnancy can lead to dehydration, electrolyte imbalance, and malnutrition. Hypoactive bowel sounds and dry mucous membranes further suggest fluid deficit and possible electrolyte disturbances. Reporting these findings allows the provider to assess severity and initiate interventions.

• Genitourinary: Oliguria and dark, concentrated urine indicate potential dehydration, which can exacerbate nausea and vomiting and compromise kidney function. Early reporting is critical to prevent complications such as acute kidney injury.

• Cardiovascular: The relative hypotension as compared to the baseline blood pressuremay reflect compensatory tachycardia due to dehydration or volume depletion. These vital sign changes warrant reporting because they help the provider assess hemodynamic stability and guide fluid management.

Rationale for incorrect findings:

• Constipation and abdominal palpation without tenderness: Mild constipation without abdominal tenderness is common in early pregnancy due to hormonal changes and is not immediately concerning. It can be managed with dietary fiber, hydration, and gentle activity.

• No edema: The absence of edema indicates no overt fluid retention or preeclampsia at this stage. While monitoring continues, this finding does not require urgent reporting.