A nurse is evaluating an infant following a motor vehicle accident.

Which signs should the nurse monitor to detect increased intracranial pressure?

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
Terbutaline does not typically cause a decrease in maternal blood glucose levels. It is a medication used to relax the muscles in the uterus to prevent premature labor.
Choice B rationale
Terbutaline does not enhance the production of fetal lung surfactant. It is used to relax the muscles in the uterus to prevent premature labor.
Choice C rationale
Weakened uterine contractions are an expected finding in a client who has received terbutaline. Terbutaline is a tocolytic medication, which means it works to inhibit uterine contractions in order to prevent or halt preterm labor.
Choice D rationale
Terbutaline does not typically cause a decrease in fetal heart rate. It is used to relax the muscles in the uterus to prevent premature labor.