A nurse is reviewing the plan of care for a 1-year-old following cleft lip and cleft palate repair.
Which of the following are developmental concerns for the infant? Potential delays in:
Fine motor skills.
Oral motor skills.
Proprioceptive skills.
Olfactory motor skills.
The Correct Answer is B
Choice A rationale
While fine motor skills may be indirectly affected, primary developmental concerns following cleft lip and palate repair center on oral motor function. The anatomical reconstruction primarily impacts feeding, speech articulation, and oral coordination, which are foundational to oral motor skill development. Fine motor development is less directly impacted by this specific surgical correction.
Choice B rationale
Cleft lip and palate repair directly impacts the oral structures essential for proper feeding and speech development, leading to potential delays in oral motor skills. Infants may experience difficulties with sucking, swallowing, and later, articulating sounds due to altered anatomy and muscle function. Early intervention and therapy are crucial to address these challenges.
Choice C rationale
Proprioceptive skills, which involve the sense of body position and movement, are not typically a primary developmental concern following cleft lip and palate repair. The surgery primarily affects the oral cavity and facial structures. While overall development can be complex, direct anatomical or neurological impact on proprioception is not a standard complication.
Choice D rationale
Olfactory motor skills, related to the sense of smell and associated motor responses, are not directly impacted by cleft lip and palate repair. The surgical intervention focuses on the oral and facial structures, not the olfactory system. Therefore, developmental delays in this specific area are not a primary concern following this type of corrective surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Routinely administering Rho(D) immune globulin at 28 weeks of gestation is a standard prophylactic measure for Rh-negative pregnant clients. This timing provides protection against potential sensitization from fetal red blood cells that may cross the placenta during the third trimester, minimizing the risk of alloimmunization and hemolytic disease of the newborn.
Choice B rationale
A spontaneous abortion, regardless of gestational age, involves a potential mixing of maternal and fetal blood, especially if the fetus is Rh-positive. Administering Rho(D) immune globulin prevents the Rh-negative mother from developing antibodies to the Rh factor, thereby protecting future Rh-positive pregnancies from hemolytic disease.
Choice C rationale
Administering Rho(D) immune globulin within 72 hours following delivery of an Rh-positive infant is crucial for Rh-negative mothers. This prevents the mother from becoming sensitized to the Rh antigen after exposure to fetal red blood cells during birth. If sensitization occurs, subsequent Rh-positive pregnancies could be affected by hemolytic disease.
Choice D rationale
Amniocentesis, a procedure involving needle insertion into the uterus, carries a risk of fetomaternal hemorrhage and potential exposure of an Rh-negative mother to Rh-positive fetal blood. Administering Rho(D) immune globulin following this procedure is a prophylactic measure to prevent maternal sensitization and protect future Rh-positive pregnancies. .
Correct Answer is D
Explanation
Choice A rationale
Allowing a client at risk for suicide to nap with the door closed poses a significant safety concern. This practice eliminates direct visual observation, which is paramount in suicide prevention. The closed door creates an opportunity for the client to engage in self-harm behaviors unobserved, increasing the risk of a successful suicide attempt by removing immediate intervention capabilities.
Choice B rationale
While distraction can be therapeutic, allowing a client on suicide precautions to engage in crafts in their room unobserved introduces potential risks. Craft materials, if not carefully monitored and selected, could be used as instruments for self-harm. Maintaining constant, direct observation, even during seemingly benign activities, is crucial to prevent access to means for suicide.
Choice C rationale
Providing headphones for relaxing music, while potentially calming, can compromise auditory monitoring of a client on suicide precautions. The headphones can obscure sounds that might indicate distress, agitation, or self-harm attempts. Direct sensory observation, including listening for abnormal sounds, is a critical component of ensuring continuous safety and prompt intervention.
Choice D rationale
Rounding and visualizing the client every 15 minutes is a fundamental suicide precaution intervention. This frequent, direct observation allows for continuous assessment of the client's behavior, mood, and immediate environment. It minimizes opportunities for self-harm by providing consistent monitoring and enables timely intervention if any concerning signs or actions are detected, ensuring client safety.
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