# A nurse in a busy outpatient pediatric clinic is performing a well-child visit on a 5-year-old child. During the visit, the child has unexplained bruising in various stages of healing on the back and posterior thighs, and the child startles when the parent speaks loudly. The parent attributes the bruises to clumsiness. Which actions are required of the nurse as a mandatory reporter? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368303&lang=en  
> language: en  
> subject: Abuse or Neglect  
> category: PSI

## Question

A nurse in a busy outpatient pediatric clinic is performing a well-child visit on a 5-year-old child. During the visit, the child has unexplained bruising in various stages of healing on the back and posterior thighs, and the child startles when the parent speaks loudly. The parent attributes the bruises to clumsiness. Which actions are required of the nurse as a mandatory reporter? Select all that apply.

1

Document the specific location, size, color, and stage of healing of each bruise objectively, with body-map diagrams

2

Wait until the bruising pattern is confirmed by a child abuse specialist before making any report

3

Confront the parent directly to determine whether the parent caused the bruises before reporting

4

Discharge the family with a follow-up appointment in 1 month and assess the bruising again at that time

5

Maintain a calm, non-judgmental demeanor and avoid leading questions when speaking with the child or parent

6

File a report with Child Protective Services (CPS) within the timeframe required by state law without confronting the parent

## Explanation

Nurses are mandatory reporters under state law for suspected child abuse, elder abuse, and intimate partner violence (varies by state). Required actions: (1) objective documentation — exact location, size, color, and stage of healing using body diagrams; this objective record protects the child and supports legal proceedings; (2) file CPS report within state-mandated timeframe (commonly within 24 to 48 hours; some require immediate verbal report followed by written) — reasonable suspicion is the threshold, not proof; the nurse does not need to confirm abuse; (4) calm non-judgmental approach with the child and parent — open-ended observations, avoid suggestion or interrogation; this protects the child from further trauma and preserves the integrity of the eventual investigation. Waiting for specialist confirmation (option 2) violates mandatory reporting timeline; reasonable suspicion is enough. Discharge with a one-month follow-up (option 4) endangers the child by delaying intervention. Confronting the parent (option 3) jeopardizes the child immediate safety, may prompt the parent to leave with the child or coach the child, and is the role of CPS investigators, not the nurse.

## In-depth explanation

Mandatory Reporter Duty
Nurses, by statute, must report suspicion of abuse — reasonable suspicion is the threshold, not proof or confirmation.

Red Flags in This Case
1. Bruising in various stages of healing (multiple injuries over time)
2. Posterior locations (back, thighs) — not typical accidental falls
3. Hypervigilance and startle response to parent voice
4. Parent explanation incongruent with pattern

Required Actions
1. Objective body-map documentation (location, size, color, stage)
2. CPS report within state-mandated time
3. Calm non-judgmental interview
4. Maintain child safety while in clinic
5. Notify provider and social work

Wrong Answers
3: Specialist confirmation not required for report.
5: Delaying equals continued harm.
6: Confronting parent equals unsafe; CPS role.

NCSBN Theme
PSI — Abuse and Neglect.

## Clinical scenario

Scenario
5-year-old, well-child visit, outpatient pediatric clinic.

Findings
- Unexplained bruising — various stages of healing
- Locations: back, posterior thighs
- Startles to loud parent voice
- Parent attributes to clumsiness

Mandated Reporter Threshold
Reasonable suspicion — proof not required

Required Response
Document objectively plus CPS report plus calm interview plus maintain safety.

## Key concepts

- **Mandatory reporter** — Statutory designation requiring certain professionals (nurses, physicians, teachers, counselors, social workers, law enforcement) to report suspected abuse of children, vulnerable adults, and elders to designated authorities within a specified timeframe. Reasonable suspicion is the legal threshold; proof is not required and reporters are protected from civil liability when reporting in good faith. Failure to report can result in license action and criminal penalty.
- **Reasonable suspicion** — Legal standard for mandatory reporting — observations, inconsistencies, or red flags (bruising patterns inconsistent with explanation, sentinel injuries, hypervigilance, fearful behavior, delayed care-seeking) that lead a reasonable nurse to suspect abuse. Lower threshold than proof; aimed at protecting the vulnerable while investigation proceeds. Documentation should be objective: what was seen, who said what.
- **Sentinel injury** — Minor injury (bruising before independent ambulation, frenulum tear, intraoral injury in pre-verbal child) that may be the only outward sign of abuse and that often precedes severe abuse. Recognition is critical because intervention at this stage prevents subsequent serious or fatal injury. Any bruising in a child under cruising age (under 9 months) warrants further evaluation.

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