# Situation: During a follow-up home visit, the nurse learns that the father, 38, lost his job 2 months ago and now drinks heavily every night. The mother, 33, has a bruise on her upper arm. Their 4-year-old son has bruises of different colors on his back and buttocks, and the mother says he "falls a lot." There is also a 7-month-old daughter. Which action should the nurse take FIRST for the 4-year-old boy?

> source: MyMerci (mymerci.kr)  
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> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: During a follow-up home visit, the nurse learns that the father, 38, lost his job 2 months ago and now drinks heavily every night. The mother, 33, has a bruise on her upper arm. Their 4-year-old son has bruises of different colors on his back and buttocks, and the mother says he "falls a lot." There is also a 7-month-old daughter.

Which action should the nurse take FIRST for the 4-year-old boy?

## 보기

1. Teach the mother positive discipline methods at the next home visit
2. Check that the boy is safe and report to the social welfare office **✔ 정답**
3. Rank the problem with the others using the prioritization scale
4. Ask the father, with the mother present, to explain the bruises

**정답: 2**

## 해설

Bruises of different ages on protected areas such as the back and buttocks, with an explanation that does not fit, suggest physical abuse, and safety issues override the usual prioritization of family problems, so the nurse first makes sure the child is safe now. Under the reporting rules of the Special Protection of Children Against Abuse, Exploitation and Discrimination Act (RA 7610), government employees whose work involves children, including the nurse, must report possible abuse to the Department of Social Welfare and Development (DSWD), usually through the local social welfare office, and the attending physician or nurse and the head of a hospital or clinic must report within 48 hours. The police and the Barangay Council for the Protection of Children (BCPC) are additional channels that any person may use, not a substitute for this report. Parenting teaching can follow later, and the suspected abuser is not confronted.

## 심화 해설

Priority rationale The 4-year-old has bruises of different colors on the back and buttocks, which are protected, non-bony areas. A history that “he falls a lot” does not match this distribution. Bruises in various stages of healing on protected areas, paired with an implausible explanation, are a classic red flag for inflicted injury. In the nursing process, actual or potential safety threats to a dependent child take precedence over family teaching, problem ranking, or interviewing a suspected abuser. The first step is therefore to secure the child’s immediate safety and activate the mandated reporting pathway.

Why not the other options Teaching positive discipline is important but is a later, secondary intervention; it does not address the current danger. Ranking this problem with other family issues using a prioritization scale is inappropriate because child safety is not one problem among equals—it overrides routine family problem ranking. Asking the father to explain the bruises while the mother is present risks further intimidation, denial, or escalation, and it delays the legal duty to report. Watch out! Confronting a suspected abuser before reporting can compromise the child’s safety and contaminate the investigation.

Recognition of physical abuse Hornor emphasizes that many children with severe inflicted injuries had earlier, less severe presentations that were overlooked [1]. Bruises are among the most common and earliest visible signs. The location and pattern matter more than the number. Bruises on the back, buttocks, trunk, ears, or neck in a young child should raise strong suspicion, especially when the caregiver’s story is inconsistent with the child’s developmental ability. A 4-year-old may fall during play, but falls typically produce bruises over bony prominences such as the shins, knees, elbows, or forehead—not the buttocks or back.

Developmental and injury-pattern correlation The mother’s statement that the boy “falls a lot” is a soft sign when combined with objective findings. A bruise on the upper arm of the mother also raises concern for intimate partner violence, which frequently co-occurs with child physical abuse. The 7-month-old daughter must also be assessed for safety, even though the question focuses on the 4-year-old. In a home where heavy alcohol use, unemployment stress, and adult injury are present, all children are at elevated risk.

Mandated reporting under RA 7610 Under the Special Protection of Children Against Abuse, Exploitation and Discrimination Act, the nurse is a mandated reporter. The report is made to the Department of Social Welfare and Development, usually through the local social welfare office. The attending physician or nurse and the head of a hospital or clinic must report within 48 hours. The police and the Barangay Council for the Protection of Children are additional reporting channels, but they do not replace the DSWD report. Key point! The nurse’s first action is to verify the child is safe now, then report immediately—not to wait for the next home visit.

Screening and systematic recognition Routine screening by nurses has been proposed to improve recognition of physical abuse in emergency settings . A brief screening tool used for children under 6 years can help identify cases that might otherwise be missed. This supports the idea that structured, early identification—rather than relying on a caregiver’s explanation—is a core nursing responsibility. In the home visit setting, the nurse applies the same principle: recognize the suspicious findings, prioritize safety, and report.

| Assessment finding | Clinical interpretation | Nursing implication |
| --- | --- | --- |
| Bruises of different colors on back and buttocks | Different healing stages suggest repeated trauma over time; protected-area location is suspicious for inflicted injury | Treat as possible physical abuse until proven otherwise; do not accept “falls a lot” at face value |
| Mother has a bruise on upper arm | Possible intimate partner violence; co-occurrence with child abuse is common | Assess safety of all household members; do not confront the father |
| Father drinks heavily every night after job loss | Stress and alcohol use increase risk of violence but do not excuse it | Document objectively; focus on child safety and mandated reporting |
| 7-month-old daughter present | Infants are highly vulnerable to physical abuse | Include the infant in the safety assessment and report |

Clinical reasoning summary The nurse’s first obligation is to the child’s immediate safety. Suspicious bruising on protected areas with an inconsistent history outweighs all other family concerns. The nurse confirms the child is safe at that moment, then reports to the local social welfare office as required by RA 7610. Parenting education, family problem ranking, and interviewing the suspected abuser are deferred. Early recognition of less severe injuries can prevent escalation to fatal or disabling abuse [1].References (research sources)

- [1]Physical abuse: Recognition and reporting.Research articleHornor G (2005) · DOI: 10.1016/j.pedhc.2004.06.009

## 임상 시나리오

Suspected Child Physical Abuse: First Nursing ActionSafety and mandated reporting before teaching or confrontation
Bruises of different colors on protected areas such as the back and buttocks, with an explanation that does not fit the injury, strongly suggest inflicted injury. The nurse must first ensure the child is safe now.

Under RA 7610, government employees whose work involves children, including nurses, must report suspected abuse to the DSWD, usually through the local social welfare office. The attending nurse and hospital or clinic head must report within 48 hours.

CautionDo not confront the suspected abuser before reporting. Parenting teaching and family problem ranking are secondary and must follow, not replace, the safety check and mandated report.

## 핵심 개념

- **RA 7610** — Special Protection of Children Against Abuse, Exploitation and Discrimination Act requiring mandated reporting of suspected child abuse.
- **DSWD** — Department of Social Welfare and Development, the primary agency to which suspected child abuse must be reported.
- **Mandated reporter** — A professional whose work involves children and who is legally required to report suspected abuse, such as a nurse.
- **Protected areas** — Body regions such as the back and buttocks that are not typically injured in accidental falls, raising suspicion for inflicted injury.
- **Bruises of different colors** — Bruises in various stages of healing indicating repeated trauma over time rather than a single accidental event.

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