A nurse is caring for an infant in a provider's office.

Medical History Provider Visit #1. Heart rate 144/min.

Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.

Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).

Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.

Respiratory rate 28/min.

Oxygen saturation 97% on room air.

Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.

Hydroceles are common in newborns and often go away without treatment by age.
Choice A is not correct because a hydrocele is not a genetic condition and does not require genetic counseling.
Choice B is not correct because retracting the foreskin and cleansing it several times daily is not necessary for a hydrocele.
Choice C is not correct because surgery is not always necessary for a hydrocele; it often goes away on its own.

The correct answer is Choice A.

Choice A rationale: The initial step in assessing unexplained bruising in a toddler is to gather information directly from the caregivers. This establishes a clinical baseline and allows the nurse to evaluate consistency, plausibility, and emotional responses. Bruising in toddlers can be developmental due to increased mobility, but patterns, location, and frequency matter. Normal platelet count ranges from 150,000 to 450,000/mm³; abnormal bruising may suggest thrombocytopenia, coagulopathy, or trauma. Early dialogue supports accurate documentation and escalation if needed.

Choice B rationale: While engaging the toddler may seem appropriate, their developmental stage limits reliable verbal communication. Toddlers typically lack the cognitive and linguistic capacity to describe events accurately, especially those involving trauma or abuse. Their responses may be influenced by fear, confusion, or limited vocabulary. Relying on their account prematurely risks misinterpretation and emotional distress. Assessment should prioritize adult sources first, followed by observational and clinical data to guide further action.

Choice C rationale: Notifying social services is a critical step in suspected abuse but must follow preliminary assessment and documentation. Premature reporting without context may lead to unnecessary distress for the family and compromise the integrity of the investigation. The nurse must first gather objective findings, caregiver explanations, and clinical indicators. Social services involvement is warranted when findings suggest non-accidental trauma, inconsistent histories, or high-risk environments. The decision must be evidence-informed and procedurally sound.

Choice D rationale: Notifying the provider is essential for collaborative care but should follow initial data collection. The provider relies on the nurse’s observations and caregiver input to determine next steps, including diagnostic testing or referral. Immediate escalation without context may delay appropriate triage or misdirect resources. The nurse’s role includes thorough documentation, pattern recognition, and initiating dialogue with caregivers to inform the provider’s clinical judgment. This ensures a coordinated, evidence-based response.