# A nurse notes multiple bruises in different stages of healing on a toddler. The caregiver gives an explanation that does not match the injuries. Which action should the nurse take?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397450&lang=en  
> language: en  
> subject: Informed Consent  
> category: MOC

## Question

A nurse notes multiple bruises in different stages of healing on a toddler. The caregiver gives an explanation that does not match the injuries. Which action should the nurse take?

## Option

1. Follow facility policy for reporting suspected child abuse. **✔ Correct answer**
2. Ask the caregiver to sign a statement admitting abuse.
3. Wait until the nurse is certain about what happened.
4. Tell the caregiver that the child cannot be discharged unless the story changes.

**Correct answer: 1**

## Explanation

Nurses are mandated reporters and should report suspected abuse according to law and facility policy. Certainty or caregiver admission is not required before reporting a reasonable suspicion. Threatening the caregiver or trying to obtain a confession can compromise safety and the investigation.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Suspected child abuse reporting.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Suspected child abuse reporting, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Mandated Reporter** — A professional legally required to report suspected abuse or neglect.
- **Objective Documentation** — Charting observable findings without unsupported conclusions.
- **Reasonable Suspicion** — A concern based on cues that is sufficient to trigger required reporting.

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