A nurse is caring for a newborn who presents to the pediatric emergency department for listlessness, poor feeding, and vomiting. On examination the nurse notes bilateral retinal hemorrhages. Which of the following actions should the nurse take?

In newborns and infants, certain clinical findings strongly suggest non-accidental trauma, especially when there is no clear medical explanation. Symptoms such as listlessness, poor feeding, vomiting, and retinal hemorrhages are concerning for intracranial injury. Retinal hemorrhages are particularly associated with shaking injuries that cause shearing forces in the brain and eyes. Nurses have a legal and ethical obligation to recognize and report suspected abuse immediately to protect the child and ensure further evaluation. Rationale: A. Suspected psychological maltreatment is not appropriate because the findings described are physical and neurologic in nature. Psychological abuse involves emotional harm such as rejection, isolation, or verbal abuse and does not typically present with retinal hemorrhages or neurological symptoms like vomiting and lethargy. These physical findings indicate a more severe form of trauma. B. Suspected abusive head trauma is the correct response because the combination of retinal hemorrhages, vomiting, poor feeding, and listlessness is highly suggestive of intracranial injury caused by shaking or blunt force trauma. Retinal hemorrhages are a hallmark finding associated with shearing forces in abusive head trauma. Immediate reporting is required to initiate a protective and diagnostic evaluation. C. Suspected sexual abuse is incorrect because there are no genital, anal, or behavioral indicators specifically related to sexual trauma in the findings described. The symptoms presented are neurologic and systemic rather than localized to the reproductive or urinary systems. Therefore, this does not align with the clinical presentation. D. Suspected physical neglect is incorrect because neglect typically presents with signs such as malnutrition, poor hygiene, or failure to thrive over time, rather than acute neurologic findings like retinal hemorrhages. The severity and specificity of the symptoms point toward direct physical injury rather than lack of care.