A nurse is caring for a child who is having a seizure.

Which of the following actions should the nurse take? (Select all that apply.)

Choice A rationale
Acute rheumatic fever is a complication that can occur after an infection with group A streptococcus, which causes strep throat and sometimes scarlet fever. The most common symptoms of rheumatic fever include fever, painful and tender joints, pain in the chest, fatigue, fast heart rate, palpitations, and multiple-joint inflammation. Therefore, asking if the child has had a sore throat recently is relevant as it could indicate a recent strep throat infection, which is a common precursor to acute rheumatic fever.
Choice B rationale
While injuries can lead to various health complications, they are not directly related to the development of acute rheumatic fever. Acute rheumatic fever is primarily caused by an overreaction of the body’s immune system to a strep throat or scarlet fever infection.
Therefore, recent injuries would not typically be a relevant factor in a suspected case of acute rheumatic fever.
Choice C rationale
Acute rheumatic fever is not a congenital condition, meaning it is not present from birth. It develops as a complication of strep throat or scarlet fever. Therefore, asking if the child was born with a cardiac defect would not typically be relevant in a suspected case of acute rheumatic fever.
Choice D rationale
While aspirin is often used in the treatment of rheumatic fever to reduce inflammation and pain, it is not a cause of the condition. Therefore, asking if the child has been given aspirin in the past 2 weeks would not typically be relevant in a suspected case of acute rheumatic fever.

Choice A rationale
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.