💊 NCLEX-RN Exam Prep

A nurse suspects a 5-year-old child has unexplained bruises in various stages of healing after a hospital visit for a minor fall. The child is withdrawn and avoids eye contact. What is the nurse's *initial* and most important action?

A Document the observations thoroughly in the client's medical record.
B Confront the parents directly about the suspected abuse.
C Report the suspected child abuse to the appropriate protective services agency.
D Ask the child directly if someone has hurt them.

✓ Correct Answer: Option C

Nurses are mandated reporters. If child abuse or neglect is suspected, the initial and most important action is to report it to the appropriate child protective services agency to ensure the child's safety.

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