Cleft Lip and Cleft Palate - HESI
Page 1
1. 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 a look of concern on ...
and palpating this area with the finger will determine if the palate is open cleft or closed not cleft
the typical parental reaction to an infant with an obvi
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Cleft Lip and Cleft Palate - HESI
Page 1
1. 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 a look 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 is wrong with my baby? What
is going on?" she cries.
2. 1.ID: 6975144170
Which action should the labor and delivery nurse take?
A. Explain that she has a healthy baby boy with a great cry.
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.
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 stay with the couple in
case they have any questions or need emotional support.
D. Take the infant to the neonatal intensive care unit immediately.
Since the infant is not in any respiratory or cardiovascular distress, there is no
need to admit him into the neonatal ICU.
Correct
Awarded 1.0 points out of 1.0 possible points.
3. The labor and delivery nurse knows that many infants with a cleft lip also
have a cleft palate.
4. 2.ID: 6975144172
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 is open (cleft) or closed (not cleft).
, B. Assess the inside of the infant's mouth with a pen light.
This will not determine if the infant has a cleft palate because the light is
often obscured in the infant's tiny mouth.
C. Place a sterile tongue blade in the mouth and press down.
Since the presence of a cleft palate cannot be determined by using a tongue
blade, there is no reason to use one in the mouth, sterile or non-sterile.
D. Request a computed tomography (CT) scan of the face
and mouth.
A CT scan is not used to determine if an infant has a cleft palate.
Correct
Awarded 1.0 points out of 1.0 possible points.
5. Mario and Isabella name their son Julio Jorge Rodriquez after both his
grandfathers. Julio is taken to the intermediate care nursery for observation.
The neonatologist consults with a plastic surgeon and diagnoses Julio with a
bilateral cleft lip and a complete cleft palate.
Page 2
1. 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."
2. 3.ID: 6975144161
Which action will the nurse implement first?
A. Explain that the evil eye did not cause Julio's cleft lip
and palate.
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.
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.
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 for Julio.
Correct
Awarded 1.0 points out of 1.0 possible points.
3. 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. 4.ID: 6975144157
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.
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 is believed 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.
There is no need for the nurse to talk to Mario's mother about this
request.
D. Ask Mario the rationale for putting a coin on the belly button.
The nurse does not need to understand or accept a client's cultural
beliefs but the nurse should respect and support the beliefs if they do
not harm the client.
Correct
Awarded 1.0 points out of 1.0 possible points.
5. Later in the day, Isabella holds Julio and discusses what will happen to
Julio with the nurse. Isabella asks, "Will Julio ever look normal?"
6. 5.ID: 6975144164
How should the nurse respond?
A. Offer to schedule a meeting with the parents of a child who has
been treated for cleft lip.
This response does not address Isabella's question regarding the
"normalcy" of Julio's appearance.
B. Share with Isabella that Julio will look normal following surgery
to repair his lip.
This is false reassurance because even with plastic surgery Julio will
probably have a scar on his lip.
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