A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

B) Vastus lateralis:

This is the correct site for administering IM injections to newborns, including vitamin K. The vastus lateralis muscle, located in the anterolateral aspect of the thigh, is the preferred site for IM injections in infants because it is well-developed, has few major blood vessels and nerves, and provides good absorption of the medication. It is recommended to divide the thigh into thirds and administer the injection in the middle third.

A) Ventrogluteal:

While the ventrogluteal site is commonly used for IM injections in adults and older children, it is not typically recommended for newborns due to the size of the muscle and potential risk of injury to underlying structures.

C) Dorsogluteal:

The dorsogluteal site is not recommended for IM injections in newborns due to the risk of injury to the sciatic nerve and other deep structures in the gluteal region.

D) Deltoid:

The deltoid muscle is not typically used for IM injections in newborns due to its smaller size and less-developed muscle mass compared to the vastus lateralis. It is more commonly used in older children and adults for certain vaccines and medications.

A) Increase the client's fluid intake:

While maintaining adequate hydration is essential for postpartum recovery, it is not the priority intervention in this situation. The client's increased blood loss requires immediate attention to prevent complications such as hemorrhage.

B) Prepare to administer oxytocic medication:

Oxytocic medication may be indicated to stimulate uterine contractions and control bleeding in postpartum clients experiencing excessive bleeding. However, before administering medication, assessing the client's condition and determining the cause of bleeding is necessary to ensure appropriate intervention.

C) Palpate the client's uterine fundus:

This is the priority nursing intervention. Saturating two perineal pads with blood in a 30-minute period suggests excessive bleeding, which could be due to uterine atony or other postpartum complications. Palpating the uterine fundus helps assess for uterine tone, position, and any signs of uterine atony. If the fundus is boggy or deviated from the midline, it indicates uterine atony and requires immediate intervention.

D) Assist the client on a bedpan to urinate:

While assisting the client with urination is important for comfort and prevention of urinary retention, it is not the priority intervention in this situation. Assessing and managing the cause of excessive bleeding take precedence to prevent further complications.