Mary is a 17-year-old teenager who thinks

Mary is a 17-year-old teenager who thinks she may be pregnant because she has missed two periods. Her last menstrual period was about one month ago. She states she had a little bit of spotting last week but didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the morning. This is her first office visit, and she is not sure why she feels so crummy but suspects she might be pregnant. Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis. Mary is a junior in high school who stands on her feet while working at Subway after school. She drinks soda daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for headaches and ibuprofen for menstrual cramps. Mary weighs about 105 lbs. (47.7 kg). Mary’s typical day’s diet consists of pop tarts, pizza, chocolate, cookies, and fried chicken. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants to keep the baby but has not told her parents. What patient history has clinical significance to the nurse and why? The most recent vital signs were: T: 98.6 F/37.0 C (oral) P: 76 (reg) R: 18 (reg) BP: 125/80 O2 sat: 98% on room air What patient vital signs have clinical significance to the nurse and why? GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4″ (160 cm), weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite. BMI 18 RESP: Breath sounds clear with equal aeration bilaterally ant/post, unlabored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4) HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale CHEST: Breasts tender on palpation, areola darkened and occasional veins present ABDOMEN: Soft; no masses, uterus palpable below the level of the symphysis pubis EXTREMITIES: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+ PELVIC EXAM: Vagina and cervix deep purple in color, uterus slightly enlarged, and Hegar’s sign present What patient assessment findings have clinical significance to the nurse and why? What is the nursing priority at this time? What nursing interventions will the nurse initiate based on the priority at this time?

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