HESI Pediatrics Cleft Lip and Cleft Palate Questions and Answers

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 punished." 3. Which action will the nurse implement first? A) Explain that the evil eye did not cause Julio's cleft lip and palate.INCORRECT Isabella is crying and upset and the nurse must be culturally sensitive and not negate her concern, the"mal de ojo" can be discussed later. B) Tell Isabella that no one knows the exact reason that this happens.INCORRECT Isabella is crying and upset and will not be willing to listen to facts at this time. C) Make a referral to a Mexican folk practitioner if one is available.INCORRECT This would be a very culturally sensitive intervention if available but it is not the best initial intervention. D) Allow Isabella to cry and verbalize her feelings of grief and guilt.CORRECT The typical parental reaction to an infant with an obvious malformation is guilt, disappointment, grief, sense of loss, and anger. The nurse should allow Isabella to cry and ventilate her feelings. There will be time later to discuss the etiology and pathophysiology of the condition, and the treatment options forJulio. Mario is waiting outside Isabella's room the next morning and tells the nurse, "Our parents want this special family coin put on Julio's belly button." Mario and Isabella respect their family's cultural beliefs. 4. How should the nurse respond to this request? A) Explain that a coin, even a special one, cannot be put on the infant's belly button.INCORRECT This is not culturally sensitive. B) Show Mario how to clean the coin and place it on Julio's umbilicus.CORRECT In the Mexican-American culture, placing a key, coin, or other metal object on the infant's umbilicus isbelieved to promote healing; the nurse must recognize which practices are harmless and respect the custom. In a time of crisis, a person's cultural beliefs are extremely important. C) Tell Mario that the nurse must talk to his mother about the reason for this request.INCORRECT