HESI Case Studies–Pediatrics-Cleft Lip and Cleft Palate (Julio Rodriquez) – Flashcards
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1. Isabella is frightened, and she has not seen her newborn son yet. She asks what's wrong with him. what action should the labor and delivery nurse take?
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Answer Isabella's questions and allow her to see her son
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2. Which assessment technique will determine if the infant has cleft palate?
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Insert a gloved finger and palpate the top of the infant's mouth
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3. Which action will the nurse implement first (evil eye)?
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Allow Isabella to cry and verbalize her feelings of grief and guilt
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4. How should the nurse respond to this request (special coin)?
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Show Mario how to clean the coin and place it on Julio's umbilicus
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5. Isabella asks "will Julio ever look normal?" How should the nurse respond?
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Show Isabella pictures of infants who have undergone cosmetic surgery
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6. What action should the nurse take based on these vitals signs?
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Document the vital signs in Julio's chart
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7. Based on Julio's behavior, how should the nurse respond?
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Document this behavior in the chart as a normal Moro reflex
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8. Isabella doesn't want to take a sitz bath. What action should the primary nurse take?
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Ask Isabella why she does not want to take a sitz bath
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9. The nurse is bringing Julio into Isabella's room from the nursery. Which action will the nurse implement first?
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Confirm that the infant and mother identification bands match
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10. Isabella states that she understands that Julio will have difficulty feeding but asks why? How should the nurse respond?
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"Formula sucked into Julio's mouth escapes through the cleft and out his nose"
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11. Which statement indicates that Isabella understands the correct way to feed Julio?
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"I must use a bottle with a special nipple when feeding my son"
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12. Which goal must be met before discharging Julio from the hospital?
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The parents will feed Julio to demonstrate the proper feeding method
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13. Mario asks the nurse why the repairs can't be done at the same time. How should the nurse respond?
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The cleft palate repair is delayed to allow normal palatal changes
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14. Which intervention should the nurse discuss with Julio's parents?
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Place Julio in elbow restraints for 15 minutes 5 times a day so he will be less resistant to the restraints after surgery
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15. Which interventions should the nurse implement post-op? (Select all)
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-Feed Julio with a Breck feeder and then rinse his mouth -Report bleeding from the suture site to the primary healthcare provider (HCP)
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16. Mario calls the nurse's station and tells the nurse that Julio is crying, and he thinks his son is in pain. What action should the nurse take first?
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Assess the infatn's breathing pattern and his incision site
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17. The nurse teaches Mario and Isabella how to care for Julio's incision site after discharge from the hospital. Which instruction will the nurse discuss with Julio's parents?
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Apply a thin line of antibiotic ointment to the suture line
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18. Which intervention should be included when addressing this nursing diagnosis?
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Obtain referrals for language-based learning development
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19. When discussing the long-term requirements for Julio's health maintenance, the nurse emphasizes the need for Julio to have frequent hearing tests. Which rationale supports this nursing intervention?
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An altered eustachian tube contributes to recurrent otitis media
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20. Mario asks the nurse, "Why does Julio need to see these doctors?" What is the best initial response by the nurse?
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"Julio may have improper positioning of his teeth."
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21. Which interventions should the nurse implement 6hrs post-op after the cleft palate repair? (Select all)
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-Feed soft, bland baby food mixed with water -Sit the child in an upright position and direct food to sides of the mouth
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22. The nurse discusses with Isabella how to provide care of Julio's mouth until his palate repair heals. Which instruction should the nurse include in the teaching?
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Encourage Julio to drink water after each feeding
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23. What role does the curandero have in Hispanic culture?
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The curandero is a man whose healing powers are believed to be the gift of God
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24. Mario and Isabella attend a support group they found after contacting the American Cleft Palate-Craniofacial Association. A woman tells a nurse about her daughter. How should the nurse respond first?
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That is difficult. There are no easy answers when others are ridiculing your child
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25. Throughout the child's development, which goal is a priority?
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The child develops a healthy personality and self-esteem
