A nurse is caring for a 5-year-old child who is withdrawn and has bruising on the ear and neck. Which of the following actions should the nurse take first?

This scenario involves a potential pediatric abuse situation requiring immediate nursing intervention. Application of the nursing process (assessment before action) and legal mandates for reporting suspected maltreatment is necessary to determine the priority step when physical indicators of injury are observed. Choice A rationale Discussing bruises with a parent may be necessary later, but it is not the immediate priority. If abuse is occurring, confronting the parent before completing a thorough assessment or ensuring child safety could potentially put the child at further risk. Choice B rationale Reporting to protective services is mandatory, but the nurse must first gather all clinical evidence. A complete physical exam provides the detailed data needed for an accurate and comprehensive report, ensuring all injuries are documented before the report is filed. Choice C rationale The nurse must first assess the child to identify the full extent of injuries and ensure physical stability. Systematic assessment allows for the discovery of hidden bruises or fractures, which is essential for both medical treatment and legal documentation. Choice D rationale Documentation is essential for legal and clinical purposes but follows the actual assessment. The nurse cannot document the full clinical picture accurately without performing a head-to-toe examination first to find all potential markers of physical trauma.