A nurse is caring for an infant in the emergency department. Exhibits Which of the following actions should the nurse take? (Select all that apply.)

A. This is crucial due to the potential for a spinal injury given the mechanism of the fall. Stabilizing the spine can help prevent further injury while the infant is being assessed. B. Monitoring the fontanel is important to assess for increased intracranial pressure. The anterior fontanel should be flat and level; bulging could indicate swelling or pressure. C. This is vital for evaluating neurological status and determining if there are any signs of increased intracranial pressure or brain injury. D. This is not appropriate at this time, as the infant is difficult to awaken, which could indicate a risk for aspiration. E. Measuring head circumference can help track changes and monitor for signs of increased intracranial pressure or other complications. F. While assessing reflexes may provide information on neurological function, it is not the priority compared to the other actions listed.