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.

Choice A reason: Rebound tenderness and low-grade fever suggest peritoneal irritation, often associated with appendicitis or other abdominal conditions. These findings are not specific to tracheoesophageal fistula, which primarily affects the esophagus and trachea, causing respiratory and feeding issues rather than peritoneal inflammation in newborns.

Choice B reason: Bulging fontanel and non-bilious emesis may indicate increased intracranial pressure or gastrointestinal issues like pyloric stenosis. These are not characteristic of tracheoesophageal fistula, which involves a connection between the trachea and esophagus, leading to feeding difficulties and respiratory symptoms rather than fontanel or emesis changes.

Choice C reason: A palpable olive-shaped mass is a hallmark of hypertrophic pyloric stenosis, causing projectile vomiting in infants. This finding is unrelated to tracheoesophageal fistula, which presents with esophageal obstruction or aspiration symptoms due to abnormal connections between the trachea and esophagus, not a palpable abdominal mass.

Choice D reason: Excessive drooling and choking during feeding are classic signs of tracheoesophageal fistula, where an abnormal connection between the trachea and esophagus causes aspiration or inability to swallow effectively. This leads to saliva accumulation and respiratory distress during feeding, making it the most indicative finding in newborns.