# A nurse is assessing a newborn with cleft lip and palate. Which assessment finding would be the most critical priority for immediate nursing intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542049 > language: ko > subject: Child Health ## 문제 A nurse is assessing a newborn with cleft lip and palate. Which assessment finding would be the most critical priority for immediate nursing intervention? ## 보기 1. Difficulty with parent-infant bonding due to facial appearance 2. Potential for aspiration during feeding attempts 3. Compromised airway patency with respiratory distress **✔ 정답** 4. Inadequate nutritional intake leading to weight loss **정답: 3** ## 해설 Airway compromise with respiratory distress is the highest priority per ABC framework, requiring immediate intervention. Other options like feeding issues or bonding are important but secondary to airway patency. ## 심화 해설 Understanding the Priority: Airway, Breathing, Circulation When caring for a newborn with cleft lip and palate, multiple nursing concerns arise simultaneously, including feeding difficulties, risk of aspiration, and altered parent-infant bonding. However, the NCLEX-RN examination consistently tests your ability to prioritize interventions using the ABC (Airway, Breathing, Circulation) framework. Among the options presented, compromised airway patency with respiratory distress represents an immediate threat to life and must be addressed before any other concern. Why Airway Takes Precedence Over Feeding and Aspiration It is essential to distinguish between the potential for aspiration during feeding and an actual, ongoing airway obstruction. While infants with cleft palate are indeed at increased risk for aspiration due to the direct communication between the oral and nasal cavities [1,2], this is a risk that nurses manage proactively with positioning and specialized feeding techniques. In contrast, a newborn exhibiting signs of respiratory distress—such as nasal flaring, grunting, retractions, or cyanosis—is experiencing a current airway emergency. In the clinical scenario, the structural defect, particularly when associated with syndromes like Pierre Robin sequence, can cause the tongue to fall posteriorly (glossoptosis), physically blocking the airway. This aligns with the ABC principle: a patent airway is the foundational requirement for all subsequent interventions, including safe feeding. Integrating Evidence: The Risk of Aspiration and Procedural Complications The provided evidence underscores that aspiration is a well-documented hazard during both feeding and clinical procedures. The scoping review highlights that thickened feeds are sometimes used to manage aspiration risk, though this practice can complicate feeding in infants with cleft palate [2]. More critically, the case report on nasoalveolar molding (NAM) emphasizes that even during controlled clinical procedures like impression making, there is a significant risk of foreign body aspiration, such as the incidental exfoliation of a natal tooth [3]. This reinforces the concept that the airway is vulnerable and must be the primary assessment focus. If a nurse observes that the infant is already struggling to breathe, the immediate priority is to establish a patent airway—through positioning, suctioning, or emergency intervention—before attempting any oral feeding, which could further compromise the airway and convert a potential risk into an actual aspiration event. The Secondary Nature of Nutritional and Psychosocial Needs Inadequate nutritional intake leading to weight loss is a critical long-term concern for infants with cleft lip and palate, as the oronasal communication prevents the generation of negative pressure needed for effective sucking [1,4]. Custom obturators and feeding plates are fabricated precisely to address this by occluding the palatal gap and improving feeding efficiency [1,4]. However, addressing a nutritional deficit is a secondary priority when a concurrent airway emergency exists. Similarly, difficulty with parent-infant bonding is a valid and important psychosocial nursing diagnosis. Yet, it does not pose an immediate physiological threat. The nurse can facilitate bonding and provide emotional support after the infant’s airway and breathing are stabilized. Clinical Application and Assessment Findings The nurse must perform a rapid, focused assessment. The most critical finding indicating the need for immediate intervention is an objective sign of airway compromise. This includes a respiratory rate consistently above 60 breaths per minute, significant intercostal or substernal retractions, stridor, or an oxygen saturation below 90% on pulse oximetry. The intervention would involve repositioning the infant—often in a prone or side-lying position to allow the tongue to fall forward—and ensuring emergency equipment is available. The research on digital versus tray impressions for neonates with cleft lip and palate notes that traditional methods carry a risk of material aspiration and distortion, further highlighting that any manipulation of the oral cavity in these infants requires heightened vigilance for airway protection . The nurse’s immediate role is to ensure that the airway is clear and breathing is adequate, as this forms the non-negotiable basis for all other care, including the eventual fabrication of feeding appliances to address nutritional needs.References (research sources) - [2]Examining Milk-Thickening Practices for Infants With Cleft Palate: A Scoping Review.Research articleChee-Williams JL, Cordero KN, Scherer NJ, Madhoun LL. (2025) · DOI: 10.1044/2025_ajslp-25-00267 - [3]Incidental Exfoliation of a Natal Tooth During Impression Making for Nasoalveolar Molding in an Infant With Cleft Lip and Palate.Research articleKoya S, Kalathingal II, Bhat HHK, Abdurahman R, Husain A. (2026) · DOI: 10.1177/10556656261447585 ## 임상 시나리오 Clinical Scenario A newborn with cleft lip and palate is admitted to the nursery. The nurse notes nasal flaring, subcostal retractions, and an oxygen saturation of 88% on room air. The infant's tongue appears to fall backward intermittently, causing stridor. Immediate Nursing Actions - Position the newborn in a side-lying or prone position to prevent the tongue from obstructing the airway (glossoptosis management). - Administer supplemental oxygen as ordered to maintain saturation above 92%. - Suction the oropharynx gently if secretions are audible and contributing to obstruction. - Notify the provider immediately and prepare for possible airway adjuncts such as a nasopharyngeal airway. - Keep emergency equipment (bag-valve-mask, intubation supplies) at the bedside. Ongoing Monitoring - Continuous pulse oximetry and cardiorespiratory monitoring. - Assess breath sounds, work of breathing, and color every 15-30 minutes until stable. - Monitor for signs of aspiration during any feeding attempts once the airway is secure. Family Support and Education - Once the infant is stable, introduce parents to the cleft care team (plastic surgery, speech pathology, feeding specialist). - Demonstrate specialized feeding techniques using a cleft palate nipple and upright positioning to reduce aspiration risk. - Provide emotional support and acknowledge feelings about the infant's appearance, connecting with support groups as appropriate. ## 핵심 개념 - **ABC framework** — Airway, Breathing, Circulation prioritization model used in nursing to address life-threatening conditions first. - **glossoptosis** — Posterior displacement of the tongue that can obstruct the airway, often seen in Pierre Robin sequence with cleft palate. - **Pierre Robin sequence** — A congenital condition characterized by micrognathia, glossoptosis, and often cleft palate, increasing airway obstruction risk. - **cleft palate** — A congenital split in the roof of the mouth creating direct communication between oral and nasal cavities, increasing aspiration risk. - **respiratory distress** — A state of compromised breathing evidenced by nasal flaring, grunting, retractions, or cyanosis requiring immediate intervention. ## 같은 주제 문제 - [A 2-month-old infant with bilateral cleft lip and palate is being assessed by the nurse. 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