A nurse is assessing a 3-month-old infant in the emergency department. The caregiver reports that the baby “rolled off the couch” and has bruising on the ear and cheek. Based on the TEN-4-FACESp bruising screening tool, what is the priority nursing action?

Choice A reason: The TEN-4-FACESp tool identifies bruising on the ear and cheek in a 3-month-old as high-risk for non-accidental trauma, as infants this age lack mobility to roll and injure themselves. Reporting to child protective services is the priority to ensure the infant’s safety, as such bruising suggests possible abuse. Choice B reason: Assuming bruising is accidental based on the caregiver’s explanation ignores the TEN-4-FACESp tool, which flags ear and cheek bruising in a non-mobile 3-month-old as suspicious for abuse. This assumption risks missing non-accidental trauma, making it an unsafe and incorrect action without further investigation. Choice C reason: Reassuring the caregiver that bruising is normal is inappropriate, as 3-month-olds are non-mobile and unlikely to bruise accidentally. The TEN-4-FACESp tool indicates ear and cheek bruising as high-risk for abuse, requiring investigation, not dismissal, making this action incorrect and potentially harmful to the infant. Choice D reason: Educating on mobility and monitoring for more bruising delays critical action. A 3-month-old cannot roll off a couch, and ear/cheek bruising per TEN-4-FACESp suggests abuse. Immediate reporting to child protective services is needed, not education or monitoring, making this an incorrect priority action.