# A 2-month-old infant with bilateral cleft lip and palate is being assessed by the nurse. Which assessment finding would be the MOST concerning and require immediate intervention?

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## 문제

A 2-month-old infant with bilateral cleft lip and palate is being assessed by the nurse. Which assessment finding would be the MOST concerning and require immediate intervention?

## 보기

1. Difficulty with bottle feeding and frequent spitting up
2. Nasal speech quality when the infant cries
3. Visible gap in the upper lip extending to the nostril
4. Signs of respiratory distress with cyanosis around the lips **✔ 정답**

**정답: 4**

## 해설

Respiratory distress with cyanosis indicates compromised airway and oxygenation, requiring immediate intervention. Other findings are expected in cleft lip/palate infants but are not immediately life-threatening.

## 심화 해설

Clinical Reasoning and Prioritization

When assessing an infant with a congenital anomaly such as bilateral cleft lip and palate, the nurse must apply the clinical reasoning framework of airway, breathing, and circulation (ABCs). While structural defects of the lip and palate present challenges with feeding and communication, the most critical assessment is the patency and function of the airway. Infants are obligate nasal breathers until approximately 5 months of age, meaning they preferentially breathe through the nose and only switch to oral breathing during crying [1]. A cleft palate disrupts the separation between the oral and nasal cavities, but it does not typically cause an intrinsic airway obstruction. Therefore, any sign of respiratory distress in this population signals a potentially life-threatening complication that must be addressed before feeding or structural concerns.

Analysis of the Correct Answer (Option 4)

Signs of respiratory distress with cyanosis around the lips is the most concerning finding. Central or circumoral cyanosis indicates hypoxemia, a direct result of inadequate oxygenation. In an infant with a craniofacial anomaly, respiratory distress could stem from several mechanisms. The primary concern is airway obstruction related to glossoptosis (posterior displacement of the tongue), which is a hallmark of Pierre Robin Sequence (PRS) [2]. PRS is characterized by a triad of micrognathia, glossoptosis, and airway obstruction, and it commonly co-occurs with cleft palate [2]. The displaced tongue base can physically block the hypopharynx, leading to stridor, retractions, and cyanosis. Furthermore, congenital nasal anomalies can be fatal from birth if the nasal airway is compromised, as infants cannot instinctively maintain oral breathing when calm [1]. This finding represents a failure of the "Airway" and "Breathing" components of the ABCs and requires immediate intervention, such as repositioning (prone position to pull the tongue forward), airway adjuncts, or emergency tracheal intubation [1,2].

Analysis of Incorrect Answers

Option 1: Difficulty with bottle feeding and frequent spitting up is an expected finding in infants with a cleft lip and palate. The open communication between the mouth and nose prevents the generation of negative pressure needed for effective sucking, leading to fatigue and prolonged feeding times. Nasal regurgitation of milk is common. While this requires nursing intervention, such as using specialized cleft palate bottles and upright positioning, it is not an immediate life threat. The infant's nutritional and hydration status must be monitored, but airway compromise takes absolute priority.

Option 2: Nasal speech quality when the infant cries (hypernasality) is a characteristic feature of a cleft palate. The velopharyngeal mechanism, which normally closes off the nasal cavity from the oral cavity during speech sounds, is incompetent due to the palatal defect. Air escapes through the nose, giving the cry a nasal quality. This is a predictable structural consequence of the anomaly, not an acute complication, and is addressed later through surgical repair and speech therapy.

Option 3: A visible gap in the upper lip extending to the nostril is the defining physical characteristic of a complete cleft lip. This finding is a static anatomical observation that confirms the diagnosis. While it may be distressing for the family, it does not represent an acute change in physiological status. The nurse's role involves providing emotional support and initiating pre-operative education, but this finding does not signal a need for immediate medical intervention.References (research sources)

- [1]Successful Noninvasive Respiratory Management of an Infant with Bilateral Choanal Atresia and a Supernumerary Nostril Located on the Columella by a Mouthpiece: A Case Report.Case reportNakamura N, Kakita H, Takagi M, Asai S, Asai T, Mori M, Takeshita S, Ueda H, Aoyama M, Kishimoto M, Ito K, Yamada Y. (2023) · DOI: 10.12659/ajcr.939642

- [2]Anesthetic Consideration in Pierre Robin SequenceResearch articleHegde N, Shah M. (2026)

## 임상 시나리오

Clinical Priority: Airway Assessment in Cleft Lip/Palate

Infants with bilateral cleft lip and palate are at risk for airway complications, particularly if associated with syndromes like Pierre Robin Sequence (PRS). The nursing priority is always the ABCs (Airway, Breathing, Circulation). While feeding difficulties and structural gaps are expected, any sign of respiratory distress or cyanosis demands immediate intervention to prevent hypoxic injury.

Key Assessment Findings Requiring Immediate Action

- Respiratory Distress: Nasal flaring, grunting, retractions, and tachypnea indicate increased work of breathing.

- Cyanosis: Circumoral or central cyanosis is a late sign of hypoxemia and a pre-arrest indicator.

- Airway Obstruction: Stridor or positional difficulty breathing may indicate glossoptosis (tongue falling back), a hallmark of PRS.

Immediate Nursing Interventions

- Position the infant prone or side-lying to allow the tongue to fall forward and open the airway.

- Administer supplemental oxygen as prescribed and prepare for continuous pulse oximetry monitoring.

- Have emergency equipment (suction, appropriate-sized airway, bag-valve-mask) at the bedside.

- Notify the provider and consider the need for a nasopharyngeal airway or further airway evaluation.

Differentiating Expected vs. Critical Findings

- Expected: Feeding difficulties (inability to create suction), nasal regurgitation, hypernasal cry, and visible orofacial clefts.

- Critical: Apnea, cyanosis, oxygen desaturation, severe retractions, or lethargy related to airway compromise.

Clinical Pearl: Infants are obligate nasal breathers until about 5 months of age. A cleft palate alone does not obstruct the airway, but associated micrognathia or glossoptosis can. Always rule out airway compromise before addressing feeding or surgical planning.

## 핵심 개념

- **Obligate nasal breathers** — Infants up to approximately 5 months of age preferentially breathe through the nose and only switch to oral breathing during crying, making nasal airway patency critical.
- **Cyanosis** — A bluish discoloration of the skin and mucous membranes, such as around the lips (circumoral), indicating hypoxemia and inadequate oxygenation.
- **Pierre Robin Sequence (PRS)** — A craniofacial anomaly triad of micrognathia (small jaw), glossoptosis (posteriorly displaced tongue), and airway obstruction, often associated with cleft palate.
- **Glossoptosis** — Posterior displacement or retraction of the tongue, which can obstruct the upper airway, especially in infants with a small or recessed mandible.
- **ABC prioritization** — A clinical reasoning framework prioritizing Airway, Breathing, and Circulation as the most critical assessments to address life-threatening conditions first.

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