Solutions
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. Correct Answer Alterated nutrition, less
than body requirements.
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.
Correct Answer Document this behavior in the chart as a
normal Moro reflex.
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. Correct Answer Sucking reflex.
Palates intact.
Nares patent.
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. Correct Answer 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.
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. Correct Answer The cleft palate repair is
delayed to allow normal palatal changes.
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.