# The nurse reviews the electronic health record of a 4-month-old infant in the emergency department. Which action by the nurse is most appropriate at this time? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=617273&lang=en > language: en > subject: Legal Rights and Responsibilities > category: MOC ## Question The nurse reviews the electronic health record of a 4-month-old infant in the emergency department. Which action by the nurse is most appropriate at this time? History Vitals Labs Orders Notes Brought in by the mother at 1930 for a bruise on the face noticed after day care pickup. Triage (1935): mother states the infant rolled off the bed yesterday. Provider interview (2010): mother states a 3-year-old sibling hit the infant with a toy. Born at term. Development: holds head steady, does not yet roll over. Blue-gray patch over the sacrum documented at birth. 1935: T 36.9 C, HR 142/min, RR 36/min, SpO2 99% on room air. Weight 6.4 kg (40th percentile). Alert, feeding well, anterior fontanel soft and flat. Hgb 11.8 g/dL, platelets 295,000/mm3, PT 11.9 seconds, INR 1.0, aPTT 31 seconds. Discharge home. Follow up with pediatrician in 1 week. Acetaminophen 96 mg PO every 6 hours PRN pain. 1945 Nursing: 2-cm purple bruise on the left cheek; three oval bruises in a row on the right upper arm; sacral blue-gray patch unchanged from the newborn description. 2030 Provider: bruising consistent with reported sibling injury; family appropriate; plan discharge. 2040 Mother asks to leave soon. 1 Report the suspected abuse to child protective services now ✕ 2 Ask the charge nurse to decide whether a report is required ✕ 3 Ask the provider to reconsider the discharge before reporting ✕ 4 Complete discharge teaching and confirm the 1-week follow-up ✕ ## Explanation Any bruise in an infant younger than about 4 to 5 months who cannot roll is concerning, and here the history changed (a roll off the bed, then a sibling with a toy), the infant cannot roll, the arm bruises form a grip-like row, and coagulation studies are normal. That meets reasonable suspicion, and each mandated reporter has a personal duty to report even when the provider disagrees. Asking the charge nurse or the provider first sounds like correct chain of command, but it hands off a duty that cannot be delegated and risks the infant leaving unprotected. ## In-depth explanation Quick answer Report the suspected abuse to child protective services now (option 1). Why this is correct The chart gives reasonable suspicion even though the provider disagrees. A 4-month-old who does not yet roll cannot roll off a bed, and the mother's explanation changed between triage and the provider interview. Three oval bruises in a row on the upper arm suggest a grip, and a cheek bruise in a non-mobile infant is a sentinel injury. Normal platelets, PT, INR, and aPTT make a bleeding disorder unlikely. The mandated-reporting duty belongs to each professional who holds the suspicion, and the discharge order means the window to protect the infant is closing. Easy analogy or mental picture Mandated reporting is like a personal smoke detector: each person who smells smoke pulls their own alarm; they do not first ask the building manager whether the smoke is real. Memory hook Cannot roll, cannot fall; story changes plus grip marks = my report, now. NCLEX decision rule When the data meet reasonable suspicion of child abuse, the nurse reports personally and promptly; disagreement from the provider or a supervisor does not remove the duty. Why the other choices are wrong Asking the charge nurse to decide (option 2) is tempting because chain of command is the usual route for a disagreement with a provider, but reporting is an individual legal duty that cannot be delegated upward, and the decision would delay the report. Asking the provider to reconsider first (option 3) is tempting because collaboration is usually preferred, but the provider has already judged the bruises accidental, and the nurse's report does not depend on the provider's agreement. Completing discharge teaching (option 4) follows the written order, but sending the infant home without a report leaves a non-mobile infant with unexplained bruises unprotected. References 1Child Welfare Information Gateway (U.S. Children's Bureau)Mandated reporters must report reasonable suspicion of child abuse; the duty is individual 2CDC: About Child Abuse and NeglectDefinition and recognition of child physical abuse ## Clinical scenario Scenario A 4-month-old who cannot yet roll has a cheek bruise and a row of oval bruises on the upper arm, the mother's explanation changed between triage and the provider interview, and the provider has ordered discharge. ## Key concepts - **Mandated reporter** — A professional, including a nurse, who is personally and legally required to report reasonable suspicion of child abuse or neglect. - **Sentinel injury** — A minor visible injury such as a bruise in a non-mobile infant that may signal abuse and precede more serious harm. - **Reasonable suspicion** — The legal threshold for reporting child abuse; proof or a confirmed diagnosis is not required. ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617273&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617273&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617273&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617273&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617273&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. 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