The parents of an infant with a cleft palate ask the nurse, "What follow-up care will our infant need after the repair?" Which is an accurate response by the nurse?

Correct Answer: D

Rationale: In this scenario, option D, which states that the infant will need follow-up with audiologists and orthodontists, is the correct response by the nurse. Following the repair of a cleft palate, infants often require multidisciplinary care to address potential issues related to speech development, feeding difficulties, and dental alignment. Audiologists are needed to assess hearing, as children with cleft palate may be at increased risk for hearing problems. Orthodontists are essential for monitoring dental and facial growth to ensure proper alignment as the child grows. Option A is incorrect because infants with a repaired cleft palate typically require ongoing follow-up care. Option B is also incorrect as evaluation by an audiologist alone is not sufficient to address the comprehensive needs of a child with a cleft palate. Option C is incorrect because while speech pathology may be necessary, it is not the only follow-up care required for infants with a cleft palate. Educationally, this question highlights the importance of understanding the comprehensive and multidisciplinary care required for children with cleft palate. It underscores the role of different healthcare professionals in providing holistic care and emphasizes the importance of ongoing monitoring and intervention to support optimal development in these children.

Correct Answer: A

Rationale: In this scenario, the most appropriate nursing action is option A) Encourage the mother to express her feelings. This response is the best choice because it acknowledges the mother's emotional state, validates her feelings, and fosters open communication. Encouraging the mother to express her feelings allows her to process her emotions, seek support, and begin to cope with the situation positively. Option B) Explain in simple language that the baby has a cleft lip may be tempting as it addresses the immediate question, but it lacks the emotional support and understanding that the mother needs at this moment of distress. Option C) Provide emotional support until the practitioner can talk to the mother is also not the best choice because the nurse should initiate the support and communication with the mother herself. Option D) Tell the mother a pediatrician will talk to her as soon as the baby is examined delays the emotional support and information the mother needs in that critical moment. In an educational context, it is crucial for nurses to prioritize therapeutic communication and empathy in situations involving unexpected or challenging diagnoses. By supporting the mother emotionally and encouraging her to express her feelings, nurses can establish trust, provide holistic care, and empower families to cope effectively with the healthcare challenges they face.

Correct Answer: B

Rationale: In the context of preoperative nursing care for an infant with a cleft lip, performing a baseline physical and behavioral assessment is the most important priority. This is because assessing the infant's current health status, including any underlying conditions, developmental stage, and behavioral patterns, is crucial for planning individualized care and ensuring a safe surgical outcome. Initiating discharge teaching (Option A) is not a priority at the preoperative stage as the focus should be on immediate preoperative preparation. Observing for allergic reactions to preoperative antibiotics (Option C) is important but not as critical as performing a baseline assessment to ensure the infant's readiness for surgery. Determining if the defect exists in other family members (Option D) is not a priority in the preoperative period and does not impact the immediate care needs of the infant. In an educational context, understanding the rationale behind prioritizing baseline assessments in preoperative care emphasizes the importance of thorough assessment in nursing practice. It underscores the need for individualized care planning based on comprehensive data collection to ensure the best outcomes for pediatric surgical patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Give pain medication to the infant to minimize crying. It is essential to provide pain relief to the infant post-surgery to ensure their comfort and well-being. Pain management is crucial in enhancing the infant's healing process and preventing unnecessary distress. Option A) Provide crib toys for distraction is incorrect because while distraction can be helpful, managing pain should be the priority in this situation. Option B) Breast- or bottle-feeding can begin immediately is incorrect because after cleft lip repair surgery, the healthcare provider usually provides specific instructions on feeding techniques to prevent complications. Immediate feeding may not be recommended. Option D) Leave the infant in the crib at all times to prevent suture strain is incorrect as it is important for the infant to have supervised time outside the crib for bonding, interaction, and development, while following any specific post-operative care instructions. Educationally, it is crucial for nurses to understand the significance of pain management in pediatric care, especially post-surgery. Proper pain management not only ensures the infant's comfort but also promotes optimal healing and recovery. Parents should be educated on the importance of pain relief and guided on appropriate administration of pain medication as per the healthcare provider's instructions.

Correct Answer: C

Rationale: The correct answer is C) 3 months. At around 3 months of age, infants begin to show signs of recognizing familiar faces and objects, such as their own hand. This is a crucial developmental milestone as it indicates the infant's growing ability to distinguish between different stimuli in their environment and form attachments with primary caregivers. Option A) 1 month is too early for infants to demonstrate recognition of familiar faces and objects. At 1 month, infants are still in the early stages of visual development and are primarily focused on basic reflexes and sensory exploration. Option B) 2 months is also too early for infants to exhibit recognition of familiar faces and objects. While infants may start to show preferences for certain stimuli at this age, true recognition typically emerges around 3 months. Option D) 4 months is past the typical age for when infants begin to recognize familiar faces and objects. By 4 months, infants should already be displaying signs of recognition and familiarity with people and objects in their environment. Understanding infant developmental milestones is essential for pediatric nurses as it helps them assess and support the growth and well-being of infants under their care. Recognizing when infants should start to demonstrate certain behaviors can guide nurses in providing appropriate developmental support and interventions when needed.