Cleft Lip and Cleft Palate Case Study

Pediatrics Cleft Lip and Cleft Palate Questions and Answers Cleft Lip and Cleft Palate Meet the Client: Julio Rodriquez Mario and Isabella Rodriquez are a young Mexican-American couple who are in the labor and delivery room having their first child. Isabella had prenatal care, and both she and Mario attended childbirth classes. Mario and Isabella's parents are in the waiting room along with other family members includingsisters, brothers, and cousins. A Complication Occurs "Push, push, push!" Mario urges while holding Isabella's hand and watching as his first-born child makes an entrance into the world. As the infant is delivered, the entire room becomes quiet and Isabella sees a look of concern on her husband's face. The baby boy is crying loudly, but the upper lip appears to be missing, and his face looks deformed. The infant is quickly placed under the radiant warmer and dried. His 1 minute Apgar score is 8. Isabella is frightened, and she has not seen her newborn son yet. "What is wrong with my baby? What is going on?" she cries. 1. Which action should the labor and delivery nurse take? A) Explain that she has a healthy baby boy with a great cry. INCORRECT Her son may be healthy and have a great cry, but he has a facial abnormality that will require repair. B) Wait for the obstetrician to tell Isabella what is happening. INCORRECT The nurse should implement another action without waiting for the obstetrician to talk to Isabella. C) Answer Isabella's questions and allow her to see her son. CORRECT The nurse should answer Isabella's questions and allow her to see her son since he is crying and not in immediate danger. This will allow for bonding between the mother and her baby. The nurse should stay with the couple in case they have any questions or need emotional support. D) Take the infant to the neonatal intensive care unit immediately. INCORRECT Since the infant is not in any respiratory or cardiovascular distress, there is no need to admit him into the neonatal ICU. The labor and delivery nurse knows that many infants with a cleft lip also have a cleft palate. 2. Which assessment technique will determine if the infant has a cleft palate? A) Insert a gloved finger and palpate the top of the infant's mouth. CORRECT The palate is the roof of the mouth, and palpating this area with the finger will determine if the palate is open (cleft) or closed (not cleft). B) Assess the inside of the infant's mouth with a pen light. INCORRECT This will not determine if the infant has a cleft palate because the light is often obscured in the infant's tiny mouth. C) Place a sterile tongue blade in the mouth and press down. INCORRECT Since the presence of a cleft palate cannot be determined by using a tongue blade, there is no reason to use one in the mouth, sterile or non-sterile. D) Request a computed tomography (CT) scan of the face and mouth. INCORRECT A CT scan is not used to determine if an infant has a cleft palate. Mario and Isabella name their son Julio Jorge Rodriquez after both his grandfathers. Julio is taken to the intermediate care nursery for observation. The neonatologist consults with a plastic surgeon and diagnoses Julio with a bilateral cleft lip and a complete cleft palate. Therapeutic Communication The nurse walks into Isabella's room during the night shift and finds her alone and crying uncontrollably. She tells the nurse, "It is my fault Julio is deformed. I got the mal de ojo, the evil eye, while I was pregnant. I put raw eggs under my bed but that still didn't help. I am being punished." 3. Which action will the nurse implement first? A) Explain that the evil eye did not cause Julio's cleft lip and palate. INCORRECT Isabella is crying and upset and the nurse must be culturally sensitive and not negate her concern, the "mal de ojo" can be discussed later. B) Tell Isabella that no one knows the exact reason that this happens. INCORRECT Isabella is crying and upset and will not be willing to listen to facts at this time. C) Make a referral to a Mexican folk practitioner if one is available. INCORRECT This would be a very culturally sensitive intervention if available but it is not the best initial intervention. D) Allow Isabella to cry and verbalize her feelings of grief and guilt. CORRECT The typical parental reaction to an infant with an obvious malformation is guilt, disappointment, grief, sense of loss, and anger. The nurse should allow Isabella to cry and ventilate her feelings. There will be time later to discuss the etiology and pathophysiology of the condition, and the treatment options for Julio. Mario is waiting outside Isabella's room the next morning and tells the nurse, "Our parents want this special family coin put on Julio's belly button." Mario and Isabella respect their family's cultural beliefs. 4. How should the nurse respond to this request? A) Explain that a coin, even a special one, cannot be put on the infant's belly button. INCORRECT This is not culturally sensitive. B) Show Mario how to clean the coin and place it on Julio's umbilicus. CORRECT In the Mexican-American culture, placing a key, coin, or other metal object on the infant's umbilicus is believed to promote healing; the nurse must recognize which practices are harmless and respect the custom. In a time of crisis, a person's cultural beliefs are extremely important. C) Tell Mario that the nurse must talk to his mother about the reason for this request. INCORRECT There is no need for the nurse to talk to Mario's mother about this request. D) Ask Mario the rationale for putting a coin on the belly button. INCORRECT The nurse does not need to understand or accept a client's cultural beliefs but the nurse should respect and support the beliefs if they do not harm the client. Later in the day, Isabella holds Julio and discusses what will happen to Julio with the nurse. Isabella asks, "Will Julio ever look normal?" 5. How should the nurse respond? A) Offer to schedule a meeting with the parents of a child who has been treated for cleft lip. INCORRECT This response does not address Isabella's question regarding the "normalcy" of Julio's appearance. B) Share with Isabella that Julio will look normal following surgery to repair his lip. INCORRECT This is false reassurance because even with plastic surgery Julio will probably have a scar on his lip. C) Tell Isabella that surgery will make a difference in Julio's appearance. INCORRECT This is not the best response. It is too vague and fails to answer what Julio will look like following surgery. D) Show Isabella pictures of infants who have undergone cosmetic surgery. CORRECT Showing parents photographs of the possible cosmetic improvements as a result of surgery may help relieve the parents' anxiety and provide a sense of hope. Growth and Development Julio's vital signs are: axillary temperature 99.2° F, apical pulse 138 BPM, and respirations 52 per minute. 6. What action should the nurse take based on these vital signs? A) Document the vital signs in Julio's chart. CORRECT Normal vital signs for an infant are axillary temperature 97.7° to 99.4° F, apical pulse 120 to 160 BPM, and respirations 30 to 60 breaths/minute. B) Notify the respiratory therapist immediately. INCORRECT There is no need to contact the respiratory therapist. C) Place an oxygen mask over the mouth and nose. INCORRECT Julio does not need oxygen. If oxygen were needed, a mask is not the means of oxygen administration used for an infant. D) Hold Julio and talk in a smooth, calm voice. INCORRECT These vital signs do not indicate a need for the nurse to hold and comfort Julio. The nurse noticed that when the door to the nursery slammed Julio extended and adducted his arms, and his fingers fanned. He looked startled and then began to cry. 7. Based on Julio's behavior, how should the nurse respond? A) Ask someone to slam the door again to see if Julio has the same reaction. INCORRECT There is no need to slam the door again. Noise in the nursery should be kept to a minimum so infants are not over-stimulated. B) Document this behavior in the chart as a normal Moro reflex. CORRECT This is a description of a Moro reflex which disappears after age 3-4 months and is strongest during the first 2 months. An infant's developmental reflexes should be routinely assessed and documented. C) Notify the healthcare provider of this abnormal rooting reflex. INCORRECT Julio is not demonstrating a rooting reflex based on that reaction. The rooting reflex occurs when the infant's head turns toward a stimuli when touched, especially at the corner of the mouth. D) Request that another nurse assess Julio's hands, arms, and legs. INCORRECT This behavior does not require another nurse to assess Julio. Management On Isabella's second postpartum day, an unlicensed assistive personnel (UAP) has been assigned certain tasks to help care for her. Upon entering the room, the nurse hears Isabella tell the UAP that she will not take a sitz bath. The UAP tells Isabella that she must take a sitz bath as directed by the healthcare provider. 8. What action should the primary nurse take? A) Do not take any action since Isabella must take a sitz bath. INCORRECT The client has the right to refuse treatment. B) Tell the UAP not to force Isabella to take a sitz bath. INCORRECT The nurse should not correct (or embarrass) the UAP in front of a client. The nurse should ask the UAP to leave the room to correct the UAP's action in a more private area. C) Ask Isabella why she does not want to take a sitz bath. CORRECT The nurse should first address the client and determine the reason for refusing treatment. Some Hispanic postpartum women may not wish to sit in a bathtub, take sitz baths, or wash their hair for 6 weeks after delivery. In such cases, warm compresses instead of a sitz bath can be used. D) Report the UAP's behavior to the charge nurse. INCORRECT The nurse must assess the situation before reporting any inappropriate, unsafe, unethical, or illegal behavior to the charge nurse. The nurse is bringing Julio into Isabella's room from the nursery. 9. Which action will the nurse implement first? A) Securely place the infant in Isabella's arms. INCORRECT The nurse can put Julio in his mother's arms, but the nurse must implement another action first. B) Ask Isabella to state her child's first and last name. INCORRECT This action is indicated, but it is not the first intervention the nurse should implement. C) Confirm that the infant and mother identification bands match. CORRECT Policies and procedures have been implemented to ensure that no mistaken identity takes place when taking infants from the nursery to the mother's room. Checking the infant's identification band with the mother's band is the priority nursing intervention. D) Determine how long Isabella wants Julio to remain in her room. INCORRECT This action is indicated, but there are more important interventions that should be implemented first. Feeding Issues Two days after Julio is born, Isabella and Mario are concerned but eager to learn how to care for their son. Isabella tells the nurse, "I understand that Julio will have trouble feeding. Can you explain that to me?" 10. How should the nurse respond? A) "Julio's facial muscles are not fully formed which causes difficulty feeding." INCORRECT Julio's facial muscles are fully formed. B) "Formula sucked into Julio's mouth escapes through the cleft and out his nose." CORRECT The cleft palate occurs because the two midline fissures of the palate fail to fuse in utero which causes a gap between the roof of the mouth and nose. C) "Are you worried that you will have trouble feeding Julio?" INCORRECT This is a therapeutic response which is indicated when addressing Isabella's feelings, but she is asking for information. So, she should be given the requested information rather than a response that focuses on her feelings. D) "The cleft palate will not allow Julio to form a good seal around the nipple." INCORRECT The cleft lip, not the palate, reduces the infant's ability to suck. The nurse discusses the special techniques that must be used to feed Julio for the next 3 months prior to the surgery that will repair his cleft lip. 11. Which statement indicates that Isabella understands the correct way to feed Julio? A) "I cannot breastfeed my son because of his cleft lip." INCORRECT Breastfeeding is encouraged for infants with a cleft lip/palate, but most infants will likely need to be bottle fed. B) "I should hold Julio in a supine position while feeding him." INCORRECT The infant should be held in a more upright position to help prevent aspiration. C) "I must use a bottle with a special nipple when feeding my son." CORRECT Modification of feeding techniques is needed to ensure that Julio receives adequate nourishment. Obturators, unique nipples, and a variety of feeders are widely available to fit the infant's needs. D) "I will not burp my son until he has finished drinking the bottle." INCORRECT Because infants with clefts tend to swallow more air when feeding, frequent burping is important. It may also reduce the incidence of flatulence and spitting up. Since Mario and Isabella are first-time parents and Julio has special needs, the nurse is concerned about Mario and Isabella's ability to feed their son correctly. 12. Which goal must be met before discharging Julio from the hospital? A) The parents will watch videos explaining the proper feeding technique. INCORRECT Watching videos may help parents learn how to feed their infant, but it is not the most important goal prior to discharge. B) The parents will feed Julio to demonstrate the proper feeding method. CORRECT Demonstration is the best means to determine the successful learning of the skill. Mario and Isabella should demonstrate for the nurse that they can competently feed their son prior to discharge. C) The parents will attend at least one support group meeting for parents. INCORRECT Attending a support group meeting is encouraged, but it will not determine if the parents can feed their son correctly. D) The parents will be able to correctly weigh their infant on a scale. INCORRECT Weight loss may indicate if Julio is not receiving enough nourishment, but another goal is more important prior to discharge. Teaching About Future Surgery Although Mario and Isabella have talked to the plastic surgeon about surgery for Julio, they ask the nurse to explain the information more clearly. Mario asks the nurse, "Why can't the repair of the cleft lip and cleft palate be done at the same time? A year is a long time to wait to repair the cleft palate." 13. How should the nurse respond? A) "The cleft palate repair is delayed to allow normal palatal changes." CORRECT Cleft palate repair is usually delayed until 12 to 18 months of age in order to accommodate palatal changes that take place with normal growth. B) "I will ask the surgeon to discuss Julio's treatment with you again." INCORRECT The nurse can and should respond to the parent's questions. The surgeon can be contacted if further clarification is needed. C) "Surgery is too long if both the lip and palate are corrected at the same time." INCORRECT The length of surgery is not the reason why the cleft lip and palate are not corrected at the same time. D) "The cleft lip is corrected early so that Julio will not have any speech problems." INCORRECT Even with good anatomic closure of the lip and palate, the majority of children will have some degree of speech impairment. In preparation for the future surgical repair of the cleft lip, the nurse discusses Julio's needs during the early postoperative period and tells Mario and Isabella about actions they can begin now to help prepare Julio for that time. 14. Which intervention should the nurse discuss with Julio's parents? A) Keep Julio in a prone position as much as possible so he will become accustomed to the position before surgery. INCORRECT The infant will be positioned on the back or side after surgery, not in the prone position. B) Hold Julio as much as possible since he is likely to cry more than the average baby during the preoperative period and need comforting. INCORRECT Julio is not predisposed to cry more than the average baby in the early postoperative period, nor does this action help to prepare him for that time. C) Practice putting a "Logan's bow" on Julio when he is sleeping at night because this device protects the incision site after surgery. INCORRECT A Logan's bow is an arched metal device taped to the cheeks to protect the suture line from tension following lip repair, but it is not placed on the infant prior to surgery. D) Place Julio in elbow restraints for 15 minutes 5 times a day so he will be less resistant to the restraints after surgery. CORRECT Following lip repair surgery, infants are placed in elbow restraints to prevent rubbing or disturbing the suture line. Practicing this activity will reduce the irritability and resistance associated with the change in routine. Mario and Isabella have demonstrated how to safely care for Julio and they are taking him home. He will be seen every 2 weeks in the pediatrician's office to assess his progress and coordinate with the other members of the healthcare team who will be caring for Julio. Cleft Lip Repair Julio is now 3 months old, and he is normal for his height and weight. He is developmentally on target, and he and his parents are exhibiting normal bonding behavior. Julio successfully undergoes a repair of his cleft lip, spends an hour in the postanesthesia care unit, and then returns to the pediatric surgical unit. 15. Which intervention should the nurse implement? A) Keep Julio's elbow restraints in place at all times. INCORRECT The restraints should be removed one at a time to exercise the arms and assess for skin breakdown. B) Instruct Isabella to use a pacifier when Julio cries. INCORRECT Pacifiers, nipples, and fingers should be kept away from the infant's mouth for 7 to 10 days to reduce stress on the surgical repair and prevent accidental tearing of very fine sutures. C) Feed Julio with a Breck feeder and then rinse his mouth. CORRECT The Breck feeder has a long rubber tip that should be placed in the side of the mouth to avoid the operative area and prevent the infant from sucking on the tubing. D) Do not allow Julio to sit in any type of infant seat. INCORRECT An upright or infant-seat position is useful in the immediate postoperative period to help prevent aspiration. It also provides the infant a change in position and offers a different perspective of the surrounding environment. Mario calls the nurse's station and tells the nurse that Julio is crying, and he thinks his son is in pain. 16. What action should the nurse take first? A) Medicate the infant with a prescribed non-narcotic analgesic. INCORRECT Although some pain medications might be needed, the nurse should take another action before medicating the infant. B) Instruct Mario to talk to the infant while Julio is lying in the crib. INCORRECT Mario's voice may relax and reduce Julio's anxiety level which might help to ease his pain, but this is not the best initial intervention. C) Determine when Julio received the last dose of his pain medication. INCORRECT This will help to prevent overmedicating Julio, but it is not the best initial intervention. D) Assess the infant's breathing pattern and his incision site. CORRECT The first step of the nursing process is to assess. The nurse must first assess Julio to rule out any complications of the surgery, such as hemorrhaging or dehiscence prior to medicating for pain. The infant should receive medication if no complications are noted. The nurse teaches Mario and Isabella how to care for Julio's incision site after discharge from the hospital. 17. Which instruction will the nurse discuss with Julio's parents? A) Apply a thin line of antibiotic ointment to the suture line. CORRECT The suture line must be cleaned of formula and any serosanguineous drainage and antibiotic ointment applied to help prevent infection which can lead to scarring. B) Cleanse the suture line with hydrogen peroxide twice a day. INCORRECT The suture line must be cleaned of formula and any serosanguineous drainage with a cotton-tipped swab dipped in normal saline not hydrogen peroxide. C) Keep the Logan's bow in place except when eating. INCORRECT The infant will likely not be sent home with the Logan's bow, but Julio's parents will have to make sure that Julio does not irritate the suture line. D) Explain that a little redness is expected at the incision site. INCORRECT Redness, a little or a lot, may indicate infection, which should be reported immediately. Any infection is likely to increase scarring which is particularly unfavorable when occurring on the face. Nursing Diagnosis The healthcare team consists of nurses, physicians, and other specialists that must provide accurate information and outline a plan of action for Julio's future health care. The pediatric nurse has written the nursing diagnosis, "Altered health maintenance related to need for long-term care." 18. Which intervention should be included when addressing this nursing diagnosis? A) Obtain referrals for language-based learning development. CORRECT Speech and language learning impairments are common complications for the child born with a cleft lip and palate. Early intervention can teach parents how to listen for developing speech abnormalities that can be corrected early on. B) Provide comfort measures including holding and rocking Julio. INCORRECT This intervention would be included for a nursing diagnosis addressing acute pain. If Julio were in pain, comforting him would reduce the stress on the sutures by decreasing his crying. C) Encourage Julio's parents to discuss their fears and concerns. INCORRECT This intervention would be included for a nursing diagnosis addressing grieving related to interrupted family processes. D) Discuss the need for Isabella to not work outside the home. INCORRECT The nurse should not judge Isabella if she needs to work outside the home. As long as Julio has caregivers that understand his special needs, Isabella should feel free to work outside the home if that is her decision. When discussing the long-term requirements for Julio's health maintenance, the nurse emphasizes the need for Julio to have frequent hearing tests. 19. Which rationale supports this nursing intervention? A) Recurrent upper respiratory infections may cause a hearing loss. INCORRECT An upper respiratory infection is not a risk factor for hearing loss. B) An altered eustachian tube contributes to recurrent otitis media. CORRECT Improper drainage of the middle ear, resulting from abnormal development (cleft palate) and inefficient function of the eustachian tube contributes to recurrent otitis media with scarring of the tympanic membrane. This can lead to hearing loss if not assessed and treated early. C) A floppy tympanic membrane causes decreased hearing. INCORRECT The tympanic membrane can be scarred due to recurrent otitis media, but it is not floppy. D) The aminoglycoside antibiotics may cause high-frequency hearing loss. INCORRECT Aminoglycoside antibiotics are ototoxic but cleft lip/palate repair surgeries do not require the use of aminoglycoside antibiotics. These are powerful antibiotics that are used to treat specific bacterial infections; they are not used as a routine prophylactic. The nurse tells Mario and Isabella that Julio will need to be seen by orthodontists and prosthodonists. Mario asks the nurse, "Why does Julio need to see these doctors?" 20. What is the best initial response by the nurse? A) "Here is a pamphlet explaining the roles of the team members." INCORRECT Providing written material for the parents is indicated, but that is not the best initial response by the nurse. B) "I will request that your healthcare provider make a referral." INCORRECT A referral to the specialists is appropriate, but this is not the best initial response by the nurse. C) "Are you worried about your son having to see these doctors?" INCORRECT This is a therapeutic response which will allow Mario to verbalize his feelings, but this is not the best initial response by the nurse. D) "Julio may have improper positioning of his teeth." CORRECT Answering Mario's question in terms he will understand should be the nurse's first response. Orthodontics and prosthodontics may be needed to correct problems involving the malposition of teeth and maxillary arches. Three-month-old Julio is ready to be discharged home with his parents. Mario and Isabella, who stays at home with Julio, have shown an understanding of the discharge teaching concerning Julio's physical and developmental care. They have a list of the healthcare team members' contact numbers and numerous scheduled appointments. Julio will be back in 9 to 12 months for another surgery to repair the cleft palate. Cleft Palate Repair A week after Julio's first birthday, he returned to the hospital for repair of his cleft palate. Julio is a thriving and rambunctious toddler who is physically and developmentally on target. He is now 6 hours postoperative his cleft palate repair. 21. Which intervention should the nurse implement? A) Institute and maintain total parenteral nutrition. INCORRECT A child will not be placed on total parenteral nutrition after this surgery. B) Apply tape to secure Julio's nasogastric tube. INCORRECT There is no tube inserted into the nose during this surgery. C) Feed soft, bland baby food mixed with water. CORRECT Initially a child should be fed soft baby food mixed with water and then gradually allowed foods with a thicker consistency. A large, plastic spoon should be used, but the spoon should not be put in the mouth. The child should not be given any foods that can tear surfaces of the palate. D) Provide formula in bottles with regular nipples. INCORRECT Most children are weaned from the bottle by 8 or 9 months of age. If the child is not weaned, then a bottle with a short nipple must be used to ensure that no stress will be placed on the palatal sutures. The nurse discusses with Isabella how to provide care of Julio's mouth until his palate repair heals. 22. Which instruction should the nurse include in the teaching? A) Brush his teeth with a soft bristle toothbrush. INCORRECT Brushing the teeth should be avoided to prevent accidental tear of the palatal sutures; nothing should beput in Julio's mouth for 7-10 days. B) Encourage Julio to drink water after each feeding. CORRECT Drinking water after eating helps to rinse away any food particles and removes residual sugars from the suture line, thereby reducing the risk for infection. C) Put antibiotic ointment on the suture line. INCORRECT This suture line is in the upper part of the child's mouth, and any attempt to apply ointment to the suture line could cause damage to the palatal sutures. D) Use a pen light to check Julio's mouth. INCORRECT It is very difficult to see the roof of the mouth with or without a pen light, and forcing Julio to open his mouth could cause damage to the suture line. Isabella is in the room holding her son when Mario tells the nurse that a curandero is coming to see Julio. 23. What role does the curandero have in Hispanic culture? A) The curandero is a person who uses massage and manipulation to treat illnesses. INCORRECT That person is known as a sobadores. They treat muscle and joint problems using massage and manipulation, and they usually do not have any formal training. B) The curandero sells herbs and teas that Hispanics believe treat medical problems. INCORRECT Yerberos or Jerberos use herbs, teas, and roots to prevent or treat illnesses. These items can be purchased from a botanica, a specialty herb shop that also sells religious figurines. C) The curandero is a woman who treats conditions that are caused by witchcraft. INCORRECT Espiritistas (spiritualists) treat conditions caused by witchcraft. Amulets and prayer are a large part of the treatment. D) The curandero is a man whose healing powers are believed to be the gift of God. CORRECT In the Hispanic culture, folk healers (curanderos) are very powerful people in the community. Some prescribe over-the-counter medications, and they usually treat traditional illnesses and conditions not treated by the espiritistas. The nurse provides the family privacy while the curandero visits Julio. Julio recovers from the cleft palate repair without any complications and is discharged home. Support Group Mario and Isabella attend a support group they found after contacting the American Cleft Palate- Craniofacial Association. The meeting is conducted by a pediatric psychiatric nurse. A woman tearfully tells the nurse, "I don't know what to say to my 7-year-old daughter who cries when the kids at school make fun of her. We had the best surgeons but she still has a scar, and it is difficult for people to understand what she is saying. She hates to go to school." 24. How should the nurse respond first? A) "Your child may sense your concern about her appearance." INCORRECT Children learn from the parent's role modeling. This statement may help answer the group member's question, but should not be the nurse's first response. B) "Sometimes a child psychologist can help a child develop coping mechanisms." INCORRECT Referrals for both the child and parents are indicated, but this should not be the nurse's first response. C) "Have you discussed the situation with your child's teacher and the school nurse?" INCORRECT Requesting the help of the school staff may better the situation, but this should not be the nurse's first response. Sometimes simply educating people can increase their acceptance of a situation. Even 7-year- old children can benefit from learning about the medical condition of a fellow student. D) "That is difficult. There are no easy answers when others are ridiculing your child." CORRECT The nurse should be honest and acknowledge that this is a difficult situation to handle. This openness and honesty will help to establish a trusting relationship that may then allow for the discussion of possible recommendations to solve the problem. The nurse continues to share information and answer questions about the psychological development of children with cleft lips/palates. 25. Throughout the child's development, which goal is a priority? A) The healthcare team will provide quality care for the child/family. INCORRECT Although the healthcare team should provide quality care for the child and family, it is not the priority goal for the child's development. B) The family is knowledgeable of pertinent agencies and support groups. INCORRECT Agencies and parent groups offer help and support to families, but this is not the most important goal for the child with a cleft lip/palate. C) The child develops a healthy personality and self- esteem. CORRECT Throughout the child's development, the development of a healthy personality and self-esteem is most important. This must be a priority goal of the multidisciplinary team and family who provide the child with a safe and sound physical and emotional environment. D) Provide an environment where the child is accepted without judgment. INCORRECT That would be an ideal environment, but the child must go to school, interact in society, and play in a world that has children who don't know any better and adults who can sometimes be ignorant or cruel. Case Outcome Mario and Isabella are raising Julio in a very loving home with lots of extended family that accept Julio just as he is. He continues to grow and learn new things every day. He is very intelligent and has a contagious laugh. Mario and Isabella are very compliant with the recommendations of the healthcare team in providing for his physical and developmental needs. They take one day at a time and are confident that they will be able to help Julio confront what lies ahead. Visit the following website if you are interested in more information about birth defects. www.modimes.com