NCLEX-PN Practice Q 1
A 4-year old child is brought by her grandmother in the emergency room due to fever, chills, and difficulty walking. The nurse tries to remove the excessive clothing of the child but is reluctant. After a thorough assessment, the nurse also noted bruises around the genital area. Which of the following interventions should the nurse do first?
A. Collect the clothing and underwear of the child
B. Provide privacy and disregard the behavior of the child
C. Inform the law enforcement for a possible child abuse
D. Record all the findings
Correct Answer: C. Inform the law enforcement for a possible child abuse
Option C: Calling law enforcement is a priority action and a legal responsibility of the nurse in cases of suspected child abuse. Signs of sexual abuse in children 0-5 years of age include unexplained genital injury, avoidance to remove clothing, insist on wearing multiple garments, difficulty walking or sitting due to genital or anal pain, and signs of sexually transmitted infections.
Options A and D: Documenting and collecting evidence is an important aspect of a suspected child sexual abuse but is not the first action.
Option B: It is the responsibility of the nurse to protect the welfare of the child.