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?

Recognize the bruising as a potential indicator of non-accidental trauma and report the findings to the appropriate child protective services

Assume the bruising is accidental since the caregiver provided an explanation and document the findings

Document the findings and reassure the caregiver that bruising is normal in infants

Educate the caregiver on infant mobility and instruct them to monitor for additional bruising at home