Pediatric Nursing HESI Case Study Cleft Lip and Cleft Palate (33 Questions with Background Info Given)

Which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

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

Which therapeutic response is appropriate for the NICU nurse to give to this inquiry?

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

Health Promotion and Maintenance (Background) Client's postoperative transition goes smoothly and without incident. The nurse prepares the parents for discharge. In client's discharge instructions, the nurse tells the parents that client will need to be seen by orthodontists and prosthodontists. The mother asks the nurse, "Why does she need to see these doctors?"

"Client may have improper positioning of her teeth."

A Complication Occurs (background)

"Push, push, push!" the spouse urges while holding the client's hand and watching as their first-born child makes an entrance into the world. As the infant is delivered, the entire room becomes quiet and the mother sees a look of concern on her spouse's face. The baby girl is crying loudly, but the upper lip appears to be missing and her face looks deformed. The infant is quickly placed under the radiant warmer and dried. Her 1 minute Apgar score is 8. The mother is frightened, and she has not seen her newborn daughter yet. "What is wrong with my baby? What is going on?" she cries.

The mother asks the nurse if that will be enough milk for her infant, or if they should add formula to the breast milk. Which responses by the nurse are the best instructions to give the parents about breastfeeding their baby? (Select all that apply. One, some, or all options may be correct.)

-"The breast milk does not need formula supplementation." -"The sucking of the neonate stimulates the production of milk." -"This milk is called colostrum and contains immunoglobulins, vitamin K, and a higher protein content than mature milk."

The mother asks the nurse why her baby must suffer punishment for her indiscretions. Which response by the nurse is likely to be most helpful?

Allow the mother to cry and verbalize her feelings of grief and guilt.

Which action should the labor and delivery nurse take?

Answer the mother's questions and allow her to see her daughter.

What action should the nurse take?

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

Based on client's behavior, how should the nurse respond?

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

The nurse discusses with the mother how to provide care of client's mouth until her palate repair heals. Which instruction should the nurse include in the teaching?

Encourage client to drink water after each feeding.

In preparation for the future surgical repair of the cleft lip, the nurse discusses client's needs during the early postoperative period and tells the parents about actions they can begin now to help prepare client for that time. Which intervention should the nurse discuss with the parents?

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

What is the appropriate nursing action?

The nurse needs to document the weight loss in the EMR. (This is a 7.35% weight loss). Rationale: It is a normal finding for newborns to lose a percentage of their birth weight by the third day of life. Most newborns will lose an average of 6 to 8% of their birth weight. Weight loss over 10% of the birth weight should be further investigated. client's current weight is an 8% weight loss from her birth weight.

The nurse observes the parents identifying the likeness of client 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 allow the parents time to bond with client.

How should the nurse respond?

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

Which are the best responses by the nurse? (Select all that apply. One, some, or all options may be correct.)

-"Your breast milk is the best option and is customized to meet your baby's physiological needs" -"The breast milk production is physically beneficial to you and the baby". -"I am happy to teach you how to pump your breasts so that you can feed your baby your breast milk."

How should the nurse respond to the spouse's reaction? (Select all that apply. One, some, or all options may be correct.)

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

Which interventions should the nurse implement? (Select all that apply. One, some, or all options may be correct.)

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

The nurse explains that client will swallow excessive air as she suckles. Which other facts should the nurse include in her explanation to the father, on the importance of burping client at least 2 to 3 times during each feeding? (Select all that apply. One, some, or all options may be correct.)

-Prevent gastric distress. -Encourage adequate intake.

Based on the newborn assessment that the NICU nurse records in the EMR, which areas need to be addressed? (Select all that apply. One, some, or all options may be correct.)

-Sucking reflex -Palate intact -Nares patent

Which causative factors should a pregnant woman eliminate or avoid to prevent cleft lip and/or palate in her unborn child? (Select all that apply. One, some, or all options may be correct.)

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

The mother calls the nurse's station and tells the nurse that client is crying, and she thinks she is in pain. What action should the nurse take first?

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

Which assessment provides the best indication to the nurse that client is thriving in her environment?

Her current weight is 7 lbs 10 oz (3.45 kgs).

Later in the day, the nurse joins the parents in their room to discusses possible outcomes of client's disorder. The mother asks the nurse, "Will my baby ever look normal?" To prepare the client for surgical repair of her cleft lip, which outcome explanation by the nurse is the most important?

Show the parents pictures of infants who have undergone cosmetic surgery.

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 children develop healthy personalities and self-esteem.

Which nursing action would best help facilitate the bonding process and ease the mother's hesitation to hold her daughter?

The nurse should comment on client's (the baby's) beautiful hair while holding the baby.

Due to the mother's limited prenatal care, she and her spouse 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?

Ultrasound screening

The nurse prepares the mother's colostrum using the Haberman nipple and attempts to feed client. Which action is the most appropriate for the nurse to take?

Utilize Standard Precautions during the procedure.

Meet the Client (background)

A young couple are in the labor and delivery room having their first child. The mother had limited prenatal care, but she and her spouse attended childbirth classes. Their parents are in the waiting room along with other family members including sisters, brothers, and cousins.

When discussing the long-term requirements for client's health maintenance, the nurse emphasizes the need for her to have frequent hearing tests. Which rationale supports this nursing intervention?

An altered eustachian tube contributes to recurrent otitis media.

Psychosocial Integrity/Support Group (Background) The parents attend a support group they find after contacting the American Cleft Palate Craniofacial Association. The meeting is conducted by a pediatric psychiatric nurse. A woman in the group tearfully tells the nurse, "I don't know what to say to my 7-year-old daughter who cries when the kids at school make fun of her. We had the best surgeons but she still has a scar, and it is difficult for people to understand what she is saying. She hates to go to school."

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

Which goal must be met before discharging from the hospital?

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

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.

According to Maslow's hierarchy of needs, which nursing problem for the pediatric patient with cleft palate needs to be addressed first?

Nutritional status

Which intervention should be included when addressing this issue?

Obtain referrals for language-based learning development.