The daughter of a divorced couple is hospitalized for injuries received in an automobile accident. The custodial father is at work when the mother arrives extremely agitated and demanding to see her daughter immediately. Which action will be most appropriate for the nurse to take at this time?

Choice A reason: Prescribing medication to calm an infant is premature without investigating the cause of restlessness and prolonged wakefulness. An in-depth assessment identifies underlying issues like medical or environmental factors, making this reactive and incorrect compared to a thorough evaluation of the infant’s behavior.

Choice B reason: Reporting to a supervisor is unnecessary before assessing the infant’s restlessness and wakefulness. Conducting an in-depth investigation allows the nurse to gather data on potential causes, making this less direct and incorrect compared to initiating a thorough assessment of the infant’s condition first.

Choice C reason: Restlessness and prolonged wakefulness in an infant warrant an in-depth investigation to identify causes like medical issues, feeding problems, or environmental factors. This aligns with pediatric nursing assessment principles, ensuring a comprehensive approach to the infant’s behavior, making it the correct response for the nurse.

Choice D reason: Assuming the behavior is normal because the mother reports it dismisses potential underlying issues causing restlessness. An in-depth investigation is needed to rule out medical or environmental factors, making this incorrect, as it risks overlooking conditions requiring intervention in the infant’s care.

Choice A reason: Calling the police directly bypasses hospital protocol for suspected abuse. Contacting social services allows for a multidisciplinary evaluation of the inconsistent spiral fracture story, ensuring appropriate investigation, making this premature and incorrect compared to following hospital child protection procedures for the child.

Choice B reason: Informing the hospital administrator is less direct than contacting social services, which is trained to handle suspected abuse cases. The inconsistent injury story requires specialized assessment, making this less appropriate and incorrect for addressing the immediate concern of potential child maltreatment in the ER.

Choice C reason: Confronting the caregiver risks escalating the situation and may hinder investigation. Reporting to social services ensures a professional evaluation of the implausible injury explanation, aligning with child protection protocols, making this confrontational approach incorrect for managing suspected abuse in the hospital setting.

Choice D reason: Calling social services is the appropriate action for a spiral fracture with an inconsistent story, as it suggests possible abuse. Social services can investigate and coordinate with authorities, aligning with hospital protocols for child maltreatment, making this the correct response to ensure the child’s safety.