The nurse is caring for a newborn infant with a cleft lip and palate.
Which of the following is the FIRST priority nursing goal when caring for this infant?
Positioning to prevent fluid accumulation in the middle ear which will result in infection.
Facilitating immediate repair of the cleft palate to ease the feeding difficulties.
Assisting the mother to bond with the baby by providing emotional support.
Establishing adequate feeding and sucking to promote growth and development.
The Correct Answer is D
Choice A rationale
While positioning to prevent fluid accumulation in the middle ear is important in the care of a newborn with a cleft lip and palate, it is not the first priority. Middle ear infections are common in children with cleft palate because the muscles that open the eustachian tubes (which drain fluid from the middle ear) may not work well. However, this is typically addressed after feeding issues are managed.
Choice B rationale
Facilitating immediate repair of the cleft palate to ease feeding difficulties is important, but it is not the first priority. Surgery to repair cleft palate is usually done when the child is older,
between 6 and 12 months of age. The timing of surgery depends on the child’s overall health and the type and severity of the cleft.
Choice C rationale
Assisting the mother to bond with the baby by providing emotional support is an important aspect of care. However, it is not the first priority. The initial focus is on addressing the baby’s immediate physical needs, such as feeding and breathing.
Choice D rationale
Establishing adequate feeding and sucking is the first priority when caring for a newborn with a cleft lip and palate. Babies with a cleft palate may have difficulty creating enough suction to breastfeed or bottle-feed effectively. Special feeding techniques and equipment may be needed to help these babies get enough nutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The immediate priority when caring for a patient with facial burns, especially a 2-month-old child, is managing the airway. Burns can cause swelling and compromise the airway, leading to respiratory distress. Therefore, ensuring a patent airway is crucial in these cases.
Choice B rationale
While monitoring renal function is important in burn patients due to the risk of acute kidney injury from decreased perfusion, it is not the immediate priority.
Choice C rationale
Restoring fluid volume is a critical part of burn management. However, it is not the immediate concern when the airway could be compromised.
Choice D rationale
Assessing for shock is important in burn patients due to the risk of hypovolemic shock from fluid loss. However, airway management takes precedence.
Correct Answer is D
Explanation
Choice A rationale
Rocking the baby to sleep and then laying the baby in the crib might not alleviate the baby’s shortness of breath and irritability. While rocking can be soothing, it does not address the underlying issue of respiratory difficulty.
Choice B rationale
Taking the baby from the mother and laying the baby in the crib might not be the best advice. Separation from the mother might increase the baby’s distress and does not address the baby’s respiratory difficulty.
Choice C rationale
Feeding the baby and then laying the baby down might not be the best advice. Feeding can be difficult for a baby who is tachypneic and might increase the risk of aspiration.
Choice D rationale
Advising swaddling the baby and placing the baby on its back at a 30-degree angle in the crib is the best advice. This position can help to decrease work of breathing and increase comfort, which might help the baby to rest better.
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