Upon observing signs of possible child abuse (crying child, stained underwear with bloodlike substance), what is the nurse's appropriate action?

• A. Contact the stepfather for more information
• B. Report the suspected abuse according to facility policy
• C. Notify the parent immediately
• D. Document and monitor

Answer: (B)

When there is suspicion of child abuse, the immediate priority is the child's safety and taking appropriate action. Nurses are mandated reporters and must report suspected abuse promptly to the proper authorities in accordance with facility policy and state law. This initiates a formal investigation and helps protect the child from further harm.

Do not confront or question the family about the suspicion in a way that could influence the investigation, and do not attempt to determine the cause yourself. Contacting the stepfather or notifying the parent directly at this moment could place the child at greater risk and could compromise evidence. Documentation and monitoring are important, but they do not substitute for the required report; objective observations should be recorded and the report made as soon as possible, following policy and legal requirements.