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

A) Orthostatic hypotension:

Orthostatic hypotension, although it can occur postpartum due to changes in fluid volume and hormone levels, is not typically an immediate sign of a postpartum complication. It may occur as the body adjusts to changes after delivery but is not necessarily indicative of a complication on its own.

B) Heart rate 110/min:

A heart rate of 110/min is elevated and may indicate a postpartum complication such as hemorrhage, infection, or other cardiovascular issues. An elevated heart rate can be a sign of physiological stress or inadequate perfusion, requiring further assessment and intervention by the nurse.

C) Fundus palpable at the umbilicus:

A fundus palpable at the umbilicus is a normal finding for a client who is 12 hr postpartum. Immediately after delivery, the fundus is typically firm and located at or just below the level of the umbilicus. Over time, it should descend and become firmer as the uterus involutes.

D) Urine output of 3,000 mL in 12 hr:

An unusually high urine output of 3,000 mL in 12 hr may indicate excessive fluid loss, which could be a sign of postpartum hemorrhage. While it is essential for postpartum clients to void frequently to prevent urinary retention, such a high output warrants further investigation by the nurse to rule out complications.

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.