HESI Pediatrics Cleft Lip and Cleft Palate
Questions and Answers
Cleft Lip and Cleft Palate
Meet the Client: Julio Rodriquez
Mario and Isabella Rodriquez are a young Mexican-American couple who are in the labor and
delivery room having their first child. Isabella had prenatal care, and both she and Mario attended
childbirth classes. Mario and Isabella's parents are in the waiting room along with other family
members includingsisters, brothers, and cousins.
A Complication Occurs
"Push, push, push!" Mario urges while holding Isabella's hand and watching as his first-born
child makes an entrance into the world. As the infant is delivered, the entire room becomes
quiet and Isabella sees alook of concern on her husband's face. The baby boy is crying loudly,
but the upper lip appears to be missing, and his face looks deformed. The infant is quickly
placed under the radiant warmer and dried. His 1 minute Apgar score is 8. Isabella is frightened,
and she has not seen her newborn son yet. "What iswrong with my baby? What is going on?"
she cries.
1.
Which action should the labor and delivery nurse take?
A) Explain that she has a healthy baby boy with a
great cry.INCORRECT
Her son may be healthy and have a great cry, but he has a facial abnormality that will
require repair.
B) Wait for the obstetrician to tell Isabella what
is happening.INCORRECT
The nurse should implement another action without waiting for the obstetrician to talk to Isabella.
,C) Answer Isabella's questions and allow her to see her
,son.CORRECT
The nurse should answer Isabella's questions and allow her to see her son since he is crying and
not in immediate danger. This will allow for bonding between the mother and her baby. The
nurse should staywith the couple in case they have any questions or need emotional support.
D) Take the infant to the neonatal intensive care
unit immediately.INCORRECT
Since the infant is not in any respiratory or cardiovascular distress, there is no need to admit
him into theneonatal ICU.
The labor and delivery nurse knows that many infants with a cleft lip also have a cleft palate.
, 2.
Which assessment technique will determine if the infant has a cleft palate?
A) Insert a gloved finger and palpate the top of the
infant's mouth.CORRECT
The palate is the roof of the mouth, and palpating this area with the finger will determine if the
palate isopen (cleft) or closed (not cleft).
B) Assess the inside of the infant's mouth with a
pen light.INCORRECT
This will not determine if the infant has a cleft palate because the light is often obscured in the
infant'stiny mouth.
C) Place a sterile tongue blade in the mouth and
press down.INCORRECT
Since the presence of a cleft palate cannot be determined by using a tongue blade, there is
no reason touse one in the mouth, sterile or non-sterile.
D) Request a computed tomography (CT) scan of the face
and mouth.INCORRECT
A CT scan is not used to determine if an infant has a cleft palate.
Mario and Isabella name their son Julio Jorge Rodriquez after both his grandfathers. Julio is
taken to theintermediate care nursery for observation. The neonatologist consults with a plastic
surgeon and diagnoses Julio with a bilateral cleft lip and a complete cleft palate.
Therapeutic Communication
The nurse walks into Isabella's room during the night shift and finds her alone and crying
uncontrollably.She tells the nurse, "It is my fault Julio is deformed. I got the mal de ojo, the evil
eye, while I was pregnant. I put raw eggs under my bed but that still didn't help. I am being
Questions and Answers
Cleft Lip and Cleft Palate
Meet the Client: Julio Rodriquez
Mario and Isabella Rodriquez are a young Mexican-American couple who are in the labor and
delivery room having their first child. Isabella had prenatal care, and both she and Mario attended
childbirth classes. Mario and Isabella's parents are in the waiting room along with other family
members includingsisters, brothers, and cousins.
A Complication Occurs
"Push, push, push!" Mario urges while holding Isabella's hand and watching as his first-born
child makes an entrance into the world. As the infant is delivered, the entire room becomes
quiet and Isabella sees alook of concern on her husband's face. The baby boy is crying loudly,
but the upper lip appears to be missing, and his face looks deformed. The infant is quickly
placed under the radiant warmer and dried. His 1 minute Apgar score is 8. Isabella is frightened,
and she has not seen her newborn son yet. "What iswrong with my baby? What is going on?"
she cries.
1.
Which action should the labor and delivery nurse take?
A) Explain that she has a healthy baby boy with a
great cry.INCORRECT
Her son may be healthy and have a great cry, but he has a facial abnormality that will
require repair.
B) Wait for the obstetrician to tell Isabella what
is happening.INCORRECT
The nurse should implement another action without waiting for the obstetrician to talk to Isabella.
,C) Answer Isabella's questions and allow her to see her
,son.CORRECT
The nurse should answer Isabella's questions and allow her to see her son since he is crying and
not in immediate danger. This will allow for bonding between the mother and her baby. The
nurse should staywith the couple in case they have any questions or need emotional support.
D) Take the infant to the neonatal intensive care
unit immediately.INCORRECT
Since the infant is not in any respiratory or cardiovascular distress, there is no need to admit
him into theneonatal ICU.
The labor and delivery nurse knows that many infants with a cleft lip also have a cleft palate.
, 2.
Which assessment technique will determine if the infant has a cleft palate?
A) Insert a gloved finger and palpate the top of the
infant's mouth.CORRECT
The palate is the roof of the mouth, and palpating this area with the finger will determine if the
palate isopen (cleft) or closed (not cleft).
B) Assess the inside of the infant's mouth with a
pen light.INCORRECT
This will not determine if the infant has a cleft palate because the light is often obscured in the
infant'stiny mouth.
C) Place a sterile tongue blade in the mouth and
press down.INCORRECT
Since the presence of a cleft palate cannot be determined by using a tongue blade, there is
no reason touse one in the mouth, sterile or non-sterile.
D) Request a computed tomography (CT) scan of the face
and mouth.INCORRECT
A CT scan is not used to determine if an infant has a cleft palate.
Mario and Isabella name their son Julio Jorge Rodriquez after both his grandfathers. Julio is
taken to theintermediate care nursery for observation. The neonatologist consults with a plastic
surgeon and diagnoses Julio with a bilateral cleft lip and a complete cleft palate.
Therapeutic Communication
The nurse walks into Isabella's room during the night shift and finds her alone and crying
uncontrollably.She tells the nurse, "It is my fault Julio is deformed. I got the mal de ojo, the evil
eye, while I was pregnant. I put raw eggs under my bed but that still didn't help. I am being
