NCLEX Cleft lip/Palate Practice (EXAM 1)

At what age is cleft lip usually repaired?

A. At birth

B. 2-3 months

C. 6-12 months

D. 2-3 years

B

Rationale: cleft lip is usually repaired at 2-3 months. Cleft palate is repaired later (6-12 months)

The nurse is teaching parents about feeding their infant with cleft palate. Which instructions are correct?

A. Use a Haberman feeder or other special nipple

B. Hold the infant upright during feeding

C. Burp the infant frequently

D. Place the infant supine after feeding

E. Expect some milk to regurgitate through the nose

A, B, C, E

Rationale: supine is unsafe due to risk of aspiration. Nasal regurgitation is expected with cleft palate where suction

A nurse is caring for a newborn with cleft lip and palate. The mother states "I don't think I can ever feed my baby like this." What is the nurses first action

A. Contact social services

B. Reassure the mother that everything will be fine

C. Assess the mothers feelings and provide emotional support

D. Begin discharge teaching about speech therapy

C

Rationale: nursing process=assess first. Acknowledge feelings and provide support. Reassurance without assessment is not therapeutic

The nurse is caring for an infant 6 hours post op following cleft lip repair. Which finding requires immediate intervention?

A. The infant is sleeping on their back

B. The incision line is slightly swollen

C. The infant cries frequently and is difficult to console

D. The infant is wearing elbow restraints

C

Rationale: excessive crying puts stress on the suture line and threatens wound integrity. Positioning supine and elbow restraints are appropriate. Mild swelling is expected with

The nurse is caring for an infant 24 hrs post cleft palate repair. Which assessment finding is the highest priority to report to the provider?

A. Small amount of serosanguinous drainage at the suture line

B. The infant resists wearing elbow restraints

C. The infant attempts to suck on fingers

D. The infant has frequent coughing with clear liquid feeds

D

Rationale: Frequent coughs with feeds after palate repair suggests possible aspiration or suture breakdown, which is highest priority to report