A charge nurse in the emergency department is reviewing the data of four young children who are receiving treatment. Which of the following should alert the charge nurse to the possibility of child maltreatment?

Choice A reason: Accidental ingestion of medications is common in toddlers due to curiosity and mobility. While concerning, this scenario does not necessarily indicate maltreatment if the pills were accessible unintentionally. It reflects a need for improved safety precautions rather than abuse. Choice B reason: Not wearing a coat in a car seat during winter is not maltreatment. In fact, bulky coats are discouraged in car seats because they interfere with harness safety. This situation does not suggest abuse or neglect. Choice C reason: A submersion injury after falling into a toilet is unusual but can occur accidentally in toddlers who are mobile and curious. While supervision should be improved, this does not automatically indicate maltreatment. Choice D reason: A complex skull fracture in a 3-month-old infant is highly suspicious for maltreatment. Infants of this age lack the mobility to roll off a changing table independently, and the severity of the injury is inconsistent with the reported mechanism. This discrepancy between injury and explanation raises concern for abuse and requires further investigation.