Cleft Lip and Cleft Palate

Which therapeutic response is appropriate for the NICU nurse to give to Jose? "A cleft lip and palate is the most common birth defect in the United States." "I understand this can be upsetting. This deformity occurs early in the pregnancy, often before a woman knows she is pregnant." "There are a variety of things that can cause this. Let me access your wife's prenatal records and review it together." "Why do you ask what your wife did to cause this? You should be more supportive and less judgmental of your wife."

"I understand this can be upsetting. This deformity occurs early in the pregnancy, often before a woman knows she is pregnant."

What is the best initial response by the nurse? "Here is a pamphlet explaining the roles of the team members." "I will request that your healthcare provider make a referral." "Are you worried that your daughter has to see these doctors?" "Maria may have improper positioning of her teeth."

"Maria may have improper positioning of her teeth."

What should be the nurse's first response? "Your child may sense your concern about her appearance." "Sometimes a child psychologist can help a child develop coping mechanisms." "Have you discussed the situation with your child's teacher and the school nurse?" "That is difficult. There are no easy answers when others are ridiculing your child."

"That is difficult. There are no easy answers when others are ridiculing your child."

Jose asks the nurse if that will be enough milk for Maria, or if they should add formula to the breast milk. Which responses by the nurse are the best instructions to give Jose and Blanca about breastfeeding Maria? "The breast milk does not need formula supplementation." "If the colostrum is too watery, then formula supplementation is required to fortify it." "Blanca will need to pump five minutes more on each breast to ensure the breast is completely emptied." "If Maria needs more volume, simply mix formula with the breast milk and warm in the microwave to preserve proteins." "The sucking of the neonate stimulates the production of milk."

"The breast milk does not need formula supplementation." "The sucking of the neonate stimulates the production of milk."

Which are the best responses by the nurse? "Formula is okay until Maria has corrective surgery, then she can breastfeed." "Your breast milk is the best option and is customized to meet Maria's physiological needs." "I will request a dietary consultation with the nutritionist to find out which formula is equivalent to breast milk." "The breast milk production is physically beneficial to you and Maria".

"Your breast milk is the best option and is customized to meet Maria's physiological needs." "The breast milk production is physically beneficial to you and Maria".

How should the nurse respond to Jose's reaction? Acknowledge his concerns and notify the HCP about the unsuccessful feeding. Acknowledge his concerns and explain that all infants will leak a little bit of their feedings. Acknowledge his concerns and educate him that the open cleft cannot muffle the sounds of suckling and swallowing. Acknowledge his concerns and explain that as Blanca becomes more proficient in feeding Maria, there will be no leakage and no more noise.

Acknowledge his concerns and explain that all infants will leak a little bit of their feedings. Acknowledge his concerns and educate him that the open cleft cannot muffle the sounds of suckling and swallowing.

The client asks the nurse why her baby must suffer punishment for her discretions. Which response by the nurse is likely to be most helpful? Explain that the evil eye did not cause Maria's cleft lip and palate. Tell Blanca that no one knows the exact reason that this happens. Make a referral to a Mexican folk practitioner if one is available. Allow Blanca to cry and verbalize her feelings of grief and guilt.

Allow Blanca to cry and verbalize her feelings of grief and guilt.

According to Maslow's hierarchy of needs, which nursing diagnosis for the pediatric patient with cleft palate needs to be addressed first? Alterated nutrition, less than body requirements. Risk for altered parenting. Altered family processes. Alteration in comfort.

Alterated nutrition, less than body requirements.

When discussing the long-term requirements for Maria's health maintenance, the nurse emphasizes the need for Maria to have frequent hearing tests. Which rationale supports this nursing intervention? Recurrent upper respiratory infections may cause a hearing loss. An altered eustachian tube contributes to recurrent otitis media. A floppy tympanic membrane causes decreased hearing. The aminoglycoside antibiotics may cause high-frequency hearing loss.

An altered eustachian tube contributes to recurrent otitis media.

Which action should the labor and delivery nurse take? Explain that she has a healthy baby girl with a great cry. Wait for the obstetrician to tell Blanca what is happening. Answer Blanca's questions and allow her to see her daughter. Take the infant to the neonatal intensive care unit immediately.

Answer Blanca's questions and allow her to see her daughter.

The nurse teaches Jose and Blanca how to care for Maria's incision site after discharge from the hospital. Which instruction will the nurse discuss with Maria's parents? Apply a thin line of antibiotic ointment to the suture line. Cleanse the suture line with hydrogen peroxide twice a day. Keep the Logan's bow in place except when eating. Explain that a little bit of redness is expected at the incision site.

Apply a thin line of antibiotic ointment to the suture line.

What action should the nurse take? Do not take any action since Blanca must take a sitz bath. Tell the UAP not to force Blanca to take a sitz bath. Ask Blanca why she does not want to take a sitz bath. Report the UAP's behavior to the charge nurse.

Ask Blanca why she does not want to take a sitz bath.

Jose calls the nurse's station and tells the nurse that Maria is crying, and he thinks she is in pain. What action should the nurse take first? Medicate Maria with a prescribed nonnarcotic analgesic. Instruct Jose to talk to Maria while she is lying in the crib. Determine when Maria received the last dose of her pain medication. Assess the infant's breathing pattern and her incision site.

Assess the infant's breathing pattern and her incision site.

Which goal must be met before discharging Blanca and Maria from the hospital? The parents will watch videos explaining the proper feeding technique. Both parents will feed Maria to demonstrate the proper feeding method. The parents will attend at least one support group meeting for parents. The parents will be able to correctly weigh their infant on a scale.

Both parents will feed Maria to demonstrate the proper feeding method.

Based on Maria's behavior, how should the nurse respond? Ask someone to slam the door again to see if Maria has the same reaction. Document this behavior in the chart as a normal Moro reflex. Notify the HCP of this abnormal rooting reflex. Request that another nurse assess Maria's hands, arms, and legs.

Document this behavior in the chart as a normal Moro reflex.

The nurse discusses with Blanca how to provide care of Maria's mouth until her palate repair heals. Which instruction should the nurse include in the teaching? Brush her teeth with a soft bristle toothbrush. Encourage Maria to drink water after each feeding. Put antibiotic ointment on the suture line. Use a pen light to check Maria's mouth.

Encourage Maria to drink water after each feeding.

Which interventions should the nurse implement? Keep Maria's elbow restraints in place at all times. Instruct Blanca to use a pacifier when Maria cries. Feed Maria with a Breck feeder and then rinse her mouth. Do not allow Maria to sit in any type of infant seat. Report bleeding from the suture site to the primary HCP.

Feed Maria with a Breck feeder and then rinse her mouth. Report bleeding from the suture site to the primary HCP.

Which interventions should the nurse implement? Institute and maintain total parenteral nutrition. Apply tape to secure Maria's nasogastric tube. Feed soft, bland baby food mixed with water. Provide formula in bottles with regular nipples. Sit the child in an upright position when feeding.

Feed soft, bland baby food mixed with water. Sit the child in an upright position when feeding.

The labor and delivery nurse knows that many infants with a cleft lip also have a cleft palate. Which assessment technique will determine if the infant has a cleft palate? Insert a gloved finger and palpate the top of the infant's mouth. Assess the inside of the infant's mouth with a pen light. Place a sterile tongue blade in the mouth and press down. Request a computed tomography (CT) scan of the face and mouth.

Insert a gloved finger and palpate the top of the infant's mouth.

Which assessment provides the best indication to the nurse that Maria is thriving in her environment? Maria appears happy and content. Maria wakes up to eat every 2 to 3 hours. Maria's vital signs are stable. Maria's current weight is 7 lbs 10 oz (3.45 kgs).

Maria's current weight is 7 lbs 10 oz (3.45 kgs).

Which intervention should be included when addressing this nursing diagnosis? Obtain referrals for language-based learning development. Provide comfort measures, including holding and rocking Maria. Encourage Maria's parents to discuss their fears and concerns. Discuss the need for Blanca to not work outside the home.

Obtain referrals for language-based learning development.

In preparation for the future surgical repair of the cleft lip, the nurse discusses Maria's needs during the early postoperative period and tells Jose and Blanca about actions they can begin now to help prepare Maria for that time. Which intervention should the nurse discuss with Maria's parents? Keep Maria in a prone position as much as possible so he will become accustomed to the position before surgery. Hold Maria as much as possible because she is likely to cry more than the average baby during the preoperative period and need comforting. Practice putting a "Logan's bow" on Maria when he is sleeping at night, because this device protects the incision site after surgery. Place Maria in elbow restraints for 15 minutes 5 times a day so she will be less resistant to the restraints after surgery.

Place Maria in elbow restraints for 15 minutes 5 times a day so she will be less resistant to the restraints after surgery.

The nurse explains to Blanca and Jose that Maria will swallow excessive air as she suckles. She explains that it is important for Maria to be burped at least 2 to 3 times during each feeding. Jose asks the nurse why is it important to burp Maria.hich facts should the nurse include in her explanation to Jose, on the importance of burping Maria at least 2 to 3 times during each feeding? Prevent gastric distress. Prevent nasal congestion. Encourage adequate intake. Prevent perianal breakdown.

Prevent gastric distress. Encourage adequate intake.

Later in the day, the nurse joins Blanca and Maria in their room to discusses possible outcomes of Maria's disorder. Blanca asks the nurse, "Will Maria ever look normal?" To prepare the client for surgical repair of Maria's cleft lip, which outcome explanation by the nurse is the most important? Offer to schedule a meeting with the parents of a child who has been treated for cleft lip. Share with Blanca that Maria will look normal following surgery to repair her lip. Tell Blanca that surgery will make a difference in Maria's appearance. Show Blanca pictures of infants who have undergone cosmetic surgery.

Show Blanca pictures of infants who have undergone cosmetic surgery.

Based on the newborn assessment that the NICU nurse records in the EMR, which areas need to be addressed? Acrocyanosis. Sucking reflex. Palates intact. Moro reflex. Nares patent.

Sucking reflex. Palates intact. Nares patent.

The nurse continues to share information and answer questions about the psychological development of children with cleft lips/palates. Throughout a child's development, which goal is a priority? The healthcare team will provide quality care for children and their families. The families are knowledgeable of pertinent agencies and support groups. The children develop healthy personalities and self-esteem. Provide an environment where the children are accepted without judgment.

The children develop healthy personalities and self-esteem.

How should the nurse respond? The cleft palate repair is delayed to allow normal palatal changes. Ask the surgeon to discuss Maria's treatment with you again. Surgical duration is extensive if both the lip and palate are corrected at the same time. The cleft lip is corrected early so that Maria will not have any speech problems.

The cleft palate repair is delayed to allow normal palatal changes.

What is the appropriate nursing action? The nurse needs to have Blanca feed Maria again and then reweigh her. The nurse needs to notify the neonatologist. The nurse needs to reweigh Maria to verify the excessive weight loss. The nurse needs to document the weight loss in the EMR.

The nurse needs to document the weight loss in the EMR.

The nurse observes Blanca and Jose identifying the likeness of Maria to themselves and other family members. Based on this response, which action is the best approach for the nurse to implement next? The nurse should begin teaching the parents how to feed Maria. The nurse should explain that the Maria's deformity is not Blanca's fault. The nurse should start talking about the surgeries to correct Maria's disfigurement. The nurse should allow Jose and Blanca time to bond with Maria.

The nurse should allow Jose and Blanca time to bond with Maria.

Which nursing action would best help facilitate the bonding process and ease Blanca's hesitation to hold her daughter? The nurse should hand the infant to Jose until Blanca is ready. The nurse should comment on Maria's beautiful hair while holding Maria. The nurse should acknowledge Blanca's hesitancy, but still hand the baby to Blanca. The nurse should explain to Blanca the importance of learning to hold her baby.

The nurse should comment on Maria's beautiful hair while holding Maria.

Physiological Integrity/Psychological IntegrityDue to Blanca's limited prenatal care, she and her husband are unprepared to have an infant born with an abnormality. Which prenatal screening could have detected the presence of a cleft lip at 13 to 14 weeks' gestation? Glucose tolerance screening. Coombs screening. Alphafetoprotein screening. Ultrasound screening.

Ultrasound screening.

Which causative factors should a pregnant woman eliminate or avoid to prevent cleft lip and/or palate in her unborn child? Use of retinoids. Use of anticonvulsants. Consumption of alcohol. Smoking/secondhand smoke.

Use of retinoids. Consumption of alcohol. Smoking/secondhand smoke.

The nurse prepares Blanca's colostrum using the Haberman nipple and attempts to feed Maria. Which action is the most appropriate for the nurse to take? Utilize Universal Precautions during the procedure. Place the colostrum in the microwave prior to feeding Maria. Place a small amount of colostrum on the inner wrist to check the temperature. Take Maria to the NICU for the feeding to prevent upsetting the parents if she chokes.

Utilize Universal Precautions during the procedure.