5. Labor, birth and immediate postpartum (136-240) Flashcards by Josh Krisha

136 . Which of the following statements about Methergine is not true?
a) Methergine tablets can be given every 6-8 hours.
b) The correct dose for Methergine IM is 0.2 mg.
c) Methergine should not be administered IV.
d) Methergine IM can be given every 2-4 hours.

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137 . When examining a newborn’s ears, which of these would you hope to see?
a) Top of pina level with or slightly below the corner of the baby’s eyes.
b) Placement different on either side.
c) Top of pina level with or slightly above the corner of the baby’s eyes.
d) Ears are posteriorly rotated.

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138 . During a newborn exam, you note what feels like sagittal synostosis. What does this mean, and what is the likely outcome?
a) The sagittal suture appears closed. The likely outcome is that the head will grow long and narrow, but the brain will likely grow to the normal size.
b) The sagittal suture appears closed. The likely outcome is that the head will grow tall and thin, and the brain is unlikely to have sufficient space to grow to its usual size.
c) The sagittal suture appears wide. The likely outcome is that this will have no significant effect on head or brain growth.
d) The sagittal suture appears wide. The likely outcome is that there will be significant cognitive delays, as this condition is strongly associated with congenital CNS disorders.

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139 . Which of the following is not an indication for active management of the third stage?
a) Primipara
b) History of PPH
c) Precipitous labor
d) Prolonged labor

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140 . Which of the following observations about the neonatal chest is abnormal, as opposed to a variation of normal?
a) Structural depression of the sternum
b) Breasts enlarged and excrete milk-like substance
c) Nipples near mid-clavicular line rather than widely spaced
d) Accessory nipples

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141 . Nasal flaring, grunting, chest retractions and circumoral cyanosis are all signs of what condition?
a) Respiratory distress syndrome
b) Cardiac shunting
c) Transient tachypnea of the newborn
d) Patent foramen ovale

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142 . When assessing gestational age of a neonate using the New Ballard Scale, there are two sections, namely physical maturity (e.g. skin, lanugo) and what else?
a) Sex maturity, e.g. breast buds, genitals.
b) Palmar and plantar maturity: e.g. creases on hands, feet.
c) Neuromuscular maturity, e.g. posture, arm recoil.
d) Sensory organ maturity, e.g. eye, ear.

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143 . You want to check a neonate’s visual tracking. Which of these methods is not a valid way for checking this?
a) Move an object caudally out of the field of view and look to see if the neonate lifts their head to follow it.
b) Turn the neonate’s head to the side and look to see if the eyes move to the opposite side.
c) Move a light from right to left and look to see if the eyes track it.
d) Move a finger laterally out of the field of view and look to see if the eyes follow it.

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144 . Which of the following is not an accurate description of a suture stitch?
a) Mattress/subcuticular: drive the needle horizontally immediately below the skin for approximately 0.5 cm, exiting on the same side of the tear that it entered, the needle holder is switched to the other hand, and a stitch made on the opposite side of the tear, again horizontally, with the entry point directly across from the exit point of the preceding stitch. This is repeated.
b) Continuous/running: pronate the hand so the needle is at least perpendicular to the surface, and supinate the hand to drive it through the two sides of the laceration, perpendicular to the tear. Bring the needle out without passing through a loop of suture. Repeat 1 cm further along the tear.
c) Blanket/continuous locked: pronate the hand so the needle is at least perpendicular to the surface, and supinate the hand to drive it through the two sides of the laceration, perpendicular to the tear. Bring the needle out without passing through a loop of suture. Create a loop in the long end of the suture, and use this and the loop from the preceding stitch to tie off the stitch. Repeat 1 cm further along the tear, without cutting the suture.
d) Interrupted: pronate the hand so the needle is at least perpendicular to the surface, and supinate the hand to drive it through the two sides of the laceration, perpendicular to the tear. Perform a hand or instrument tie, and trim the ends.

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145 . The neonate you just caught is not breathing, so you start to stimulate it. Which of these do you not try?
a) Gently shake the neonate.
b) Briefly rub the neonatal back, trunk or extremities.
c) Warming, positioning, clearing secretions (if needed) and drying the neonate.
d) Flick or pinch the soles of the feet.

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146 . How would a placenta normally be expelled if it begins to separate centrally?
a) Shultz
b) Fetal side, membranes preceding.
c) Maternal side, membranes trailing.
d) Duncan

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147 . Prior to birth, your client had decided to refuse Vitamin K for their newborn, but the birth was quite traumatic, and they’re now revisiting the decision. Which of these is not accurate information?
a) IM administration is more effective than oral, even if the recommended schedule is followed. However, the oral route should be recommended for high risk babies if parents decline the IM route.
b) The solution is clear to slightly opalescent and pale yellow. If the contents are turbid or separated, discard.
c) The IM dose is a single dose of 0.5 or 1mg within an hour of birth. Oral dose recommendations vary, but one recommended schedule is 2mg within an hour of birth, repeated at 4-7 days and at 1 month. In exclusively formula-fed babies, the third dose can be omitted.
d) There is a clearly documented increase in rates of leukemia with administration of IM Vitamin K.

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148 . You’re performing a newborn exam after the Golden Hour, and have already looked at the baby’s head, neck, chest, abdomen and upper and lower extremities, palpating and listening as appropriate. You then turn the newborn over, and discover a small hole over the spine. What does this signify, and what action should you take?
a) This signifies a neural tube defect, and the parents should be told that 35% of babies with this condition die before 10 years of age. Immediate transport is required.
b) This signifies a neural tube defect, and should be brought to the attention of the baby’s pediatrician at their initial appointment.
c) This signifies spina bifida, but a small hole is not associated with particularly poor outcomes, and referral to a pediatrician at some stage in the early weeks postpartum is appropriate.
d) This signifies spina bifida, which can lead to major infections such as meningitis. Transport is appropriate.

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149 . When palpating the uterus after third stage, what finding is encouraging?
a) Fundus is firm and 2 cm above umbilicus.
b) Fundus is firm and below the umbilicus.
c) Fundus is firm and globular and displaced laterally.
d) Fundus is intermittently firm and soft.

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150 . When your client arrives in active labor, you palpate her abdomen to find that the fetus is poorly-engaged and is ROT. You listen for FHT for some time, but find none. You gently tell your client of your findings, and discuss options regarding transferring to the hospital or having a birth at the birth center. Your client has questions about legal procedure. Which of the following is true?
a) It is not compulsory that a death certificate be signed.
b) The only person who can sign a death certificate is a physician.
c) The coroner will perform an autopsy in all cases of stillbirth.
d) You will need to inform the coroner of a stillbirth.

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151 . When examining the neonatal neck, which of the following is an abnormal finding?
a) The head and neck flex laterally approximately 60 degrees to move the head towards the shoulder.
b) Lateral flexion and contralateral rotation.
c) When the head is turned to the side, the arm on that side stretches out and the opposite arm bends up at the elbow.
d) The head and neck rotate past the shoulder to approximately 110 degrees from the midline.

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152 . Nafula (G1) has had a long and tiring labor, and regression of the fetal head between contractions has been very discouraging to her. Finally, the head is born, but again retracts against the perineum. It isn’t restituting and rapidly becomes a dark purple color. Which of these do you not try?
a) Flex fetal shoulders and then corkscrew, possibly with suprapubic pressure down and towards the side that adducts the fetal shoulder impacting upon the symphysis pubis.
b) Reposition shoulders to oblique diameter and extract posterior arm, if it is within reach, sweeping the arm across the baby’s face.
c) Fundal pressure while encouraging hard pushing and assisting with traction that is strong enough to deliver the impacted shoulder.
d) Reposition Nafula, e.g. to hands and knees, running start, McRobert’s, a squat or to the end of the bed.

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153 . You’re assessing a neonate’s respiratory and cardiac function and note nasal flaring. On closer inspection, you can see that the left side of the chest is more prominent than the right, and think you can hear hyperresonance on percussion of the left anterior chest. Auscultation reveals reduced breath sounds on the left. What do you suspect, and what do you do?
a) A pneumothorax. Give blow-by oxygen and monitor closely. If nasal flaring does not improve within 30 minutes, or the neonate’s vital signs become out of normal range, transport.
b) The lung contains amniotic fluid. Use a DeLee to suction the lung and listen again. If this does not solve the issue or if nasal flaring continues, transport.
c) A pneumothorax. Transport the neonate.
d) The lung contains amniotic fluid. This is normal, and should be absorbed into the lung soon. Listen again before leaving.

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154 . The newborn has a persistent weak cry. Which of the following statements is not correct?
a) This can be a sign of postmaturity. Transport.
b) This is an abnormal cry.
c) This could be a sign of a depressed or ill infant, or of the presence of hypoglycemia.
d) Monitor closely. If there are signs of respiratory distress, prolonged hypoglycemia, jitteriness or lethargy, transport.

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155 . Nella has been laboring for about 4 hours when her membranes rupture. She begins spontaneously pushing, and you see the sacrum bulging at the perineum a few minutes later. Which of the following is not accurate?
a) The birth of the head must be completed within approximately 5 minutes of birth to the umbilicus.
b) The fetal head must be flexed when it enters the pelvis.
c) You should ensure the umbilical cord is not pulled taught, and can gently pull a little slack if it is.
d) As soon as the shoulders are born, you should gently lift the baby towards Nella’s abdomen to birth the face.

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156 . Which of the following statements about palmar surface creases of the foot is not accurate?
a) The timing of development of foot creases during gestation varies somewhat among races.
b) Abnormal creases are a sign of chromosomal anomaly, rather than a congenital deformity.
c) Until 36 weeks, there are only one or two transverse skin creases in the anterior part, with the posterior two thirds smooth.
d) A deep plantar crease between the first and second metatarsal is associated with Down’s Syndrome and other genetic disorders.

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157 . Nancy has been in active labor for 13 hours, and has been in the birth pool for about 30 minutes. You’ve been assessing FHT every 20 minutes, and the chart records the last 8 checks as: 136-144, 132-144, 128-140, 140-148, 136-146 and 146-152. When you check again now, you find FHR at 156-166 bpm. What action do you suggest, if any?
a) Ask Nancy to drink a few more sips of cool coconut water. Check FHR again in 10 minutes.
b) This is normal variation as birth nears, and no action is needed. Check FHR again in 20 minutes.
c) Check the temperature of the pool. If you suspect it is too warm, either cool it down or ask Nancy to get out the pool for a while so she can cool down. Check FHR again in 10 minutes.
d) Put a cool washcloth on Nancy’s head and replace it every few minutes. Check FHR again in 20 minutes.

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158 . You’re performing a newborn exam on a baby where the mother called you late and birth occurred shortly before you arrived. You’re looking at the molding of the neonate’s head to try to work out the position the baby had been in during labor. The skull is contracted in the suboccipitobregmatic diameter, and extended in the mentovertical diameter. Which position does this suggest?
a) Persistent occipito-posterior position
b) Brow presentation
c) Well-flexed occipito-anterior position
d) Face presentation

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159 . The newborn has a normal-sounding but persistent cry. Which of the following is an inaccurate statement?
a) If the crying does not resolve, suspect prolonged abnormal irritability (also called colic). Parents should be reassured that this is normal, albeit difficult to deal with.
b) If the neonate becomes cyanotic with crying, suspect a cardiopulmonary issue and transport.
c) Have the neonate lie skin-to-skin, dim lights and quiet the room.
d) May be a sign of pain. Look for areas of bruising or swelling and aim to avoid contact with them. Apply arnica gel.

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160 . Shortly after birth, Nathaly tells you she has extreme chest pain, and she starts to gasp for air. She looks cyanotic and then begins to seize. You call an ambulance and notify them that you have a client with suspected what? a) Transient ischemic attack. b) Uterine inversion. c) Amniotic fluid embolism. d) Disseminated intravascular coagulation.

161 . In the first week, what is the expected number of bowel movements each day from the neonate? a) Day 1: 1, Day 2: 2, Day 3: 3, Day 4: 3-4, Day 5-7: 3-5. b) Day 1-3: 1, Day 3-7: 2-3. c) Doubling every day, i.e. Day 1: 1, Day 2: 2, Day 3: 4, etc. d) Normally 1 or more each day, but 1 or 2 days with no stools is a variation of normal.

162 . Navya's baby is crowning when you discover a nuchal arm. You decide to deliver it before the head is fully born. How and why? a) You splint the humerus between 2 fingers and sweep the upper arm across the fetal face and out. This reduces the risk of a deep perineal tear and of shoulder dystocia. b) You supply traction to the fetal head, corkscrewing it out as you do so, turning in the direction of the nuchal arm. This reduces the chance of rapid changes in intracranial pressure. c) You pinch the fingers so that the fetus will extend its arm before the head is born, delivering it. This reduces the risk of shoulder dystocia. d) You rotate the fetal head 180 degrees in the direction of the nuchal hand, which means the hand passes over the face and the arm will now deliver spontaneously. This reduces the risk of a perineal tear and reduces the length of the second stage.

163 . If a newborn contracts GBS, which of the following is not a serious illness that might result? a) Meningitis b) Pneumonia c) Sepsis d) Congenital heart defects, most commonly ventricular septal defect

164 . Which of the following descriptions of skin lesions is inaccurate? a) Neonatal varicella: vesiculopustular eruption, with simultaneous lesions in differing stages of evolution. If present at birth, it is relatively mild. (If it occurs between 5-10 days, around 20% fatality rate.) b) Transient neonatal pustular melanosis: vesicopustules without erythema rupture, leaving a collarette of scale and then hyperpigmented brown macules that persist for months. c) Milia, e.g. Epstein's pearls on the gum margins, are erythematous nodules, and are normally benign and self-limiting. d) Miliaria Crystallina: clear, small 'dew drop' vesicles caused by obstruction of eccrine sweat ducts. Resolves with cooling and removal of occlusion.

165 . When examining a newborn's eyes, which of the following is a common finding, not requiring treatment or referral? a) Subconjunctival hemorrhage b) Persistent eye crusting c) Significant yellow discharge d) Tearing

166 . You're helping your client understand when their baby has a good latch. Which of the following is not a sign of a good latch? a) The baby has a generous amount of areola in their mouth, and there is no in-and-out movement of the nipple. b) The baby's lips are flanged out. c) There is more areola showing above the baby's mouth than below. d) The baby's cheeks dimple when sucking.

167 . Which of the following descriptions of abnormalities of the extremities is incorrect? a) Congenital vertical talus: rocker-bottom foot; a rigid deformity with dorsiflexed forefoot, normally requiring surgery. b) Syndactylous: fewer than 5 digits on an extremity c) Talipes: club foot; various forms of a congenital deformity of the foot, usually marked by a curled shape or twisted position of the ankle, heel and toes. d) Metatarsus adductus: a sharp, inward angle of the front half of the foot

168 . Which of these is not an accurate description of something you might record during a vaginal exam? a) Position of cervix: e.g. central, posterior, lateral. b) Effacement: percentage of the initial distance between the external os and internal os still remaining. 0-100% c) Consistency of cervix: e.g. soft or firm. d) Dilation of cervix: 0-10cm

169 . You arrive at Nancy's house shortly after she reports SROM, as the fetus had not been well-engaged at your last visit. You immediately check FHR, which are 140-152 bpm, with reactivity heard. Contractions have been regular for about 10 hours and are now 5-6 minutes apart, lasting 30-45 seconds. Her pulse is 98 bpm, temperature is 98.5F, and BP 132/86 (from pre-labor norms of 60-75 bpm, 97.2-97.9F and 110-70 to 126/82). You ask Nancy to lie down and re-check blood pressure; it's now 124/82. You ask her to produce a urine sample, which is scant but sufficient to test. Of note are ketones +2, specific gravity 1.025, a trace of protein, and it's dark in color. Nancy tells you she vomited from the pain and stress of it all just before her membranes ruptured. What do you suspect is going on? a) Chorioamnionitis b) Ketoacidosis c) Maternal dehydration d) Preeclampsia

170 . Which hormone needs to be released for letdown to occur? a) Oxytocin b) TSH c) Prolactin d) Growth hormone

171 . Which is not true about the status of membranes? a) If you cannot feel fetal hair through a cervix dilated enough for you to touch the fetus, you can be confident that membranes are intact. b) If a client reports obvious ROM but a vaginal exam reveals bulging membranes, it's likely that there has been a hind leak. c) Following ROM in a GBS positive client, aiming to reduce or avoid cervical checks, observing temperature carefully, and administering IV antibiotics is a good choice for management. d) You should check FHT immediately after ROM to check for cord prolapse.

172 . Which of the following reflexes has not been accurately described? a) Rooting: triggered by toughing a finger to the neonate's cheek or the corner of the mouth. The neonate turns the head towards the stimulus, opening the mouth and searching for the stimulus. b) Plantar: triggered by stroking across the ball of the foot or pressing into the ball of the foot with a blunt object. The toes flex. c) Stepping: triggered by holding the neonate upright and touching one foot to a flat surface. The neonate makes walking motions with both feet. d) Blinking: triggered by a loud noise. The neonate blinks.

173 . Which of the following statements regarding suture material and methods is true? a) Catgut is associated with significantly less pain than is synthetic suture. b) Repairs with synthetic suture have a significantly higher rate of wound breakdown than do repairs with catgut. c) Interrupted stitches are associated with more short-term pain than is continuous (non-locking) suturing technique. d) Coated Vicryl and Vicryl Rapide have the same properties regarding tensile strength over time and absorption rate.

174 . Which of the following does not describe a situation where perineal support is beneficial? a) The perineum blanches but client is in control of pushing: cup the perineum for the birth of the head to create slack and reduce the risk of tearing. b) The anterior fontanelle is visible, occiput is anterior: apply pressure to the perineum to obtain full flexion so the smallest diameter of the head can pass through. c) The fetal head is in military attitude, with the occiput posterior: apply pressure to the perineal membrane to obtain full flexion, reducing the presenting diameter. d) This is the client's first birth and the head is crowning rapidly: counterpressure can slow the birth of the head, reducing the risk of significant tearing.

175 . Which of the following does not accurately describe a possible cause of obstructed labor and/or appropriate management? a) Pathologic retraction ring: a localized band of myometrium goes into a tetanic contraction and becomes thickened, normally around a depression in the fetal body such as the neck, gripping the fetal part and preventing descent. The cervix may be floppy and not well-applied to the presenting part, and the uterine segment between the retraction ring and the external os remains lax during contractions. A hot sitz and foot bath and relaxing herbs such as motherwort or skullcap may resolve the situation. b) Inlet disproportion: normally associated with non-vertex presentations, malpresentation or compound presentation. Descent stops at around -3 to -2 station, and dilation likely arrests at 6 cm. Contractions may become weak or incoordinate, and there may be asymmetrical spastic pain. Strong contractions may overcome minor disproportion. c) Outlet disproportion: associated with small interischial tuberous diameter and midpelvic contraction. Descent does not stop until after +2 station. The head may dip deeply backwards towards the sacrum during late pushing, often causing a deep perineal tear. Molding or caput may be extreme. Second stage is prolonged, most commonly at the perineal phase, causing severe decelerations or bradycardia. Positions that allow maximum sacral mobility may overcome the problem. d) Midpelvic disproportion: associated with small interischial spinous diameter. Descent stops around or just below 0 station, and may not rotate to anteroposterior position. Dilation proceeds normally, but there is a prolonged second stage. Position changes and strong contractions may overcome tight interischial diameter if other dimensions are adequate.

176 . You're teaching your client how to position her baby for breastfeeding. Which is incorrect positioning? a) Baby lies on their back which she crouches over them on all fours and dangles her nipple in the baby's mouth. b) Lying on her side with the baby lying alongside her, belly to belly. c) The nipple is lined up with the baby's mouth or chin before they open their mouth to latch on. d) The neck and spine are aligned laterally, with the baby's head facing forwards, and the neck is slightly extended.

177 . You're checking femoral pulses in a newborn. Which of these is an abnormal finding, requiring immediate referral? a) Pulse equal on both sides. b) No femoral pulses felt with firm pressure. c) Femoral pulses felt on both sides d) Strong pulse palpated on only the right.

178 . Which of these is appropriate when suturing? a) When tying off suturing, ensure that both knots go the same direction. b) The needle is pushed into a stitch with needle holders, but pulled through the far side of the stitch with fingers. c) The needle holder is clamped on the junction of the needle and the suture. d) Stitches are not pulled tight.

179 . Your client is hemorrhaging postpartum, and you've decided to give her Misoprostol/Cytotec. Which route of administration will produce the fastest and most reliable results? a) Oral b) Vaginal c) Rectal d) Sublingual

180 . Which of the following best describes how to manually stimulate the postpartum uterus when PPH from atony is present? a) You should never fiddle with the fundus. Do not attempt to manually elicit a contraction. b) Drive a fist into the abdomen above the umbilicus and rock from side to side. c) Place a hand on the lower abdomen and repetitively massage or squeeze the fundus. d) Vigorously rub the skin on the lower abdomen.

181 . You're assessing a neonate's APGAR score at 5 minutes. The baby has acrocyanosis, a heart rate of 110 bpm, no response to stimulus, some flexion, and weak, irregular breathing. What score do you give, and do you need to record a 10-minute APGAR too? a) APGAR = 5. Yes, a 10-minute APGAR should be recorded. b) APGAR = 4. Yes, a 10-minute APGAR should be recorded. c) APGAR = 6. No, a 10-minute APGAR is not needed. d) APGAR = 6. Yes, a 10-minute APGAR should be recorded.

182 . Nadine has been in second stage for about 30 minutes. You're listening to FHT approximately every 5 minutes, and have been able to hear them throughout most of the last 2 contractions. Baseline is around 130-135 bpm. As the contractions have built, the FHR has gradually dropped, falling to around 96 bpm at its nadir. The rate has then gradually increased back to baseline as the contraction tapers off, and variability has been seen between contractions, including reactivity to stimulation of the fetal scalp. What do you do? a) This is a category III FHR. These long, low decelerations show fetal compromise and imply that vaginal birth is not safe for this fetus. Emergency transport is required. Call 911 and lie Nadine on her left side with oxygen at 10 l/min. b) This is a category III FHR. These decelerations show significant fetal distress, and birth must be hastened by all possible means, including position changes, coached pushing, and an episiotomy if this might hasten delivery. c) This is a category II FHR. Early decelerations alone are not considered non-reassuring, but the nadir is below the lowest 'normal' rate of 110 bpm. Careful monitoring is required, and resuscitation equipment should be checked in case it is needed. d) This is a category I FHR. Early decelerations are common in second stage, and are thought to be caused by vagal stimulation of the temporal baroreceptors as the head is compressed by the birth canal.

183 . Which of the following reflexes has not been accurately described? a) Babinski: triggered by stroking on the lateral aspect from the heel up to the ball of the foot. The great toe flexes dorsally and the other toes fan outwards laterally. b) Sucking: triggered by placing a finger or nipple in the infant's mouth. The neonate sucks forcefully and rhythmically. c) Moro: triggered by a loud noise, bright light or sudden movement. The neonate symmetrically extends extremities whilst forming a C shape with the thumb and forefinger. d) Palmar: triggered when a finger is placed in the neonate's palm. The neonate grasps the finger and spontaneously lifts their own weight.

184 . When performing a visual inspection of the vaginal and perineal area a short time after birth, you note hemorrhoids. Which of the following is not a potentially appropriate treatment? a) Witch hazel or tea tree compress. b) A diet low in fiber. c) Ice packs and/or sitz baths. d) Either the midwife or the client can lubricate a finger and push hemorrhoids back inside the rectum.

185 . Natalie calls you at 3am to report that she's having contractions. You ask her how often and how long they're lasting and she tells you she's had 3 in the last few hours, each lasting at least 20 seconds. Which of these do you not tell her? a) When Natalie loses her mucous plug or has bloody show, only then is she is in the first stage of labor, and she should call you then. b) Remind Natalie of the signs of early labor: a clear contraction pattern with contractions generally getting longer, stronger and closer together. c) Explain that this is not yet early labor, and she needs to sleep. d) Tell Natalie to have a relaxing day when she gets up in the morning, with a healthful diet and good hydration, and not too much strenuous activity.

186 . You're examining a newborn's abdomen about 90 minutes after birth. You wait until the baby is relaxed, and then gently palpate, with knees flexed towards the abdomen, and, finally, auscultate. Which of the following is an abnormal finding? a) Bruit over the liver. b) You are able to palpate a kidney. c) Abdomen is smooth and even, with no abnormal masses discovered. d) You are able to palpate the bladder, 2 cm above the symphysis.

187 . Nelly gave birth precipitously an hour ago, and you're waiting for the placenta to deliver. She hasn't emptied her bladder since you arrived, but has been sipping her drink regularly. You palpate her abdomen and, sure enough, feel a soft bulge above the pubic bone. Nelly has a history of postpartum hemorrhage, and so you decide it's important to have her bladder empty soon. However, Nelly then struggles to do so. Which of the following is not something you might need to try in order to help her? a) Perform catheterization using standard ("universal") precautions. b) Have Nelly spray herself with water from a peri bottle. c) Give her privacy and leave the tap running a little, but be nearby. d) Put peppermint oil in the toilet water.

188 . Which of the following statements about dermal melanocytosis (also known as slate gray nevi and formerly known as Mongolian spots) is incorrect? a) Unless there are very large or multiple lesions, or if dermal melanocytosis is present alongside a vascular malformation, no action is required. b) Present in up to 90% of Asian, African American and Native American infants, 50% of Hispanic infants, and 10% of white non-Hispanic infants. c) Found overlying the lumbosacral area (or, less commonly, higher on the back, onto the buttocks or upper posterior thighs), ranging in size from 5mm to 10cm or more. d) Presents as a smooth oval or circular blue or gray mole. Normally occurs as a solitary mole.

189 . When examining the neonatal neck, which of the following is a normal finding? a) Nodule palpated on the thyroid. b) Butterfly-shaped thyroid visible. c) Midline mass that moves with swallowing is palpable inferior to the hyoid bone. The mass elevates on tongue protrusion. d) Asymmetric neck, including a finding of the thyroid not on the midline.

190 . Which is not an effective management strategy for deep transverse arrest? a) Manually disengaging the head and rotating to OA (or OP if this does not work) with the client in knees-chest, followed by use of a Rebozo to loosen pelvic joints. b) Position changes that encourage correction of malpresentation or that promote pushing, such as squatting, dangling or kneeling. c) Position changes and movement that alter pelvic size and shape, such as stair climbing, lunges or dancing. d) Aim to reduce the strength of contractions with hops, skullcap, chamomile tea and relaxation techniques.

191 . Which of the following is not appropriate for suturing postpartum? a) Absorbable suture, e.g. Vicryl. b) A cutting needle. c) SH (small half circle) needle. d) 2-0 suture.

192 . You think back to recent labors you've been assistant at, specifically suggestions the primary midwife gave her client during second stage. One of them didn't seem appropriate to you. Which one? a) The client was delivering an OP baby, and the midwife suggested she lie on her left side and lift her right leg up and over, placing her foot on the bed. b) The client looked to be pushing hard, but no progress was seen, and the midwife placed her hand on the perineum and told the client to push down into that spot. c) The client was delivering a breech baby, and the midwife suggested hands and knees, dropping to knees and chest once the baby was born to the nape of the neck. d) The client was exhausted after over 2 hours of pushing, and was crying and ready to transfer to the hospital. She'd mostly been standing upright, leaning on her partner. The midwife suggested she get into a squat to push.

193 . You notice that the neonate you just delivered has tapered fingers. What does this tell you? a) The neonate has an x-linked disorder. Referral to a pediatrician is appropriate. b) There are many conditions with this feature. Referral to a pediatrician is appropriate. c) The neonate has an x-linked disorder. If no other abnormalities are seen, no further investigation is required. d) There are many conditions with this feature, but if only tapered fingers are seen, this is a benign condition with no further investigation required.

194 . You've been with your client for 2 hours and have started seeing a rise towards tachycardia in the fetal heart rate. Your client now tells you that she's having ongoing pain, not just lasting 60 seconds or so. Her membranes then spontaneously rupture, and you see pink stained amniotic fluid. What do you suspect, and what do you do? a) This is normal. Continue as usual. b) Old meconium. Monitor following 'high risk' protocol. c) Placental abruption. Transport. d) Cord prolapse. Transport.

195 . Your client has a family history of deafness, and so you are checking the patency of the neonate's ear canals. Which of these methods do you use to do so? a) Gently pull the outer ear up and back and place otoscope speculum into ear canal. You should see a pearl gray tympanic membrane. b) Gently pull the outer ear up and back and place otoscope speculum into ear canal. You should not be able to visualize anything in the ear canal. c) Gently pull the outer ear down and back and place otoscope speculum into ear canal. You should see a pearl gray tympanic membrane. d) Gently pull the outer ear down and back and place otoscope speculum into ear canal. You should not be able to visualize anything in the ear canal.

196 . You temporarily switch off the lights in the room and hold an ophthalmoscope close to your eyes, with the power off. You then project the light into both eyes of the neonate from about 18" away, individually and together. Which is a normal finding? a) Reflex is brighter in one pupil than in the other b) Absence of reflex in one pupil c) Equal and bright red reflex from the pupils d) Equal and bright gray reflex from the pupils

197 . Nesta has not been producing enough milk and you've recommended she start pumping to increase supply. Which is the most appropriate suggestion for how to do this? a) Pump after almost every feed, ideally in a relaxed situation, holding or looking at your baby. b) Pump before almost every feed, ideally holding your baby or looking at them or a photo of them if they're not with you. c) Pump 6-8 times a day, ideally whilst distracted from what you're doing. d) Pump after one or two feeds a day, ideally whilst distracted by TV or similar.

198 . Deep transverse arrest, where the fetal head descends to the ischial spines and then becomes wedged, unable to descend or to rotate to OA or OP, can be identified with which set of signs and symptoms? a) Prolonged first stage, lack of descent, coronal suture is in the transverse diameter of the pelvis, development of first stage hypotonic uterine dysfunction, extensive molding and/or caput succedaneum. b) Prolonged second stage, lack of descent, coronal suture is in the transverse diameter of the pelvis, development of second stage hypotonic uterine dysfunction, extensive molding and/or caput succedaneum. c) Prolonged first stage, lack of descent, sagittal suture is in the transverse diameter of the pelvis, development of first stage hypotonic uterine dysfunction, extensive molding and/or caput succedaneum. d) Prolonged second stage, lack of descent, sagittal suture is in the transverse diameter of the pelvis, development of second stage hypotonic uterine dysfunction, extensive molding and/or caput succedaneum.

199 . Nat recently delivered the placenta and you've been focusing on helping with initiation of breastfeeding. You check on bleeding and find a trickle bleed with estimated loss of around 400 ml. Which of these is not a finding associated with the cause listed, and a management strategy? a) Full bladder: uterus is boggy, displaced laterally. Have client empty bladder (e.g. into chux pad/catheterize), then encourage breastfeeding or nipple stimulation and/or use allopathic medication or non-allopathic treatment to stimulate contractions. b) Retained placental fragments: cotyledons fit together when placenta is gently cupped, margin appears complete. Intrauterine exploration and removal of retained fragments. c) Laceration in the vaginal vault: uterus is well-contracted and not ballooning. Suture if within scope of practice. Transfer if not. May be necessary to tie off vessel before repair. d) Clots blocking the os: fundal height rises. Express clots by pushing the well-contracted fundus to follow curve of Carus, guarding the uterus above the pubic bone.

200 . Which of the following is usually the first s/s of uterine rupture? a) Sudden loss of fetal station. b) Recurrent decelerations that become progressively deeper, or abrupt bradycardia. c) Cessation of uterine contractions. d) Maternal anxiety.

201 . Your client is showing signs of hypovolemic shock and you've activated your emergency transfer protocol. Your assistant has called 911, given the address and the situation, and is now calling the NICU to report Situation, Background, Assessment, and Recommendations. What have you been doing while they are on the phone? a) Monitoring vital signs so you can give up-to-date report to EMS and NICU. b) Encourage baby to breastfeed, stimulate contractions, give allopathic or non-allopathic treatment for hemorrhage. c) Giving the client oxygen and then tidying the birth space so that EMS do not think poorly of midwifery. This could affect the entire state! d) Maintaining an airway, giving oxygen at 6 l/min, starting an IV with clamps open, attempting to stop the bleeding.

202 . When examining a newborn's arms, which of the following is not an accurate description of a condition you might encounter? a) Klumpke's palsy: damage to the lower brachial plexus. Limp lower arm, minimal arm/hand movement, claw hand. b) Fractured clavicle: arm is held abducted and flexed. c) Amelia: absence of a limb. Hemimelia: absence of the forearms or hand. d) Erb's palsy: involves damage to upper brachial plexus. Arm is pronated, wrist flexed back, weak shoulder abduction.

203 . Which of the following is a correct management strategy when meconium stained amniotic fluid is seen? a) For all degrees of staining, there is no change to normal protocol, other than cleaning the face with a towel. b) For light or moderate staining, vaginal birth is appropriate, with no changes to normal protocol other than more frequent monitoring of FHT and then suctioning nose and then mouth on the perineum. c) For light or moderate staining, vaginal birth is appropriate, with no changes to normal protocol other than suctioning mouth and then nose on the perineum. d) Transport if thick meconium is seen. If birth occurs before arrival at the hospital, suction on the perineum.

204 . Which of the following best describes how to perform external bimanual compression? a) Stand to client's side so cranial side corresponds to dominant hand. Press non-dominant hand firmly into abdominal wall just above symphysis pubis. Place dominant hand on the fundus and push firmly posteriorly for 5-20 minutes, then gradually attempt to release, monitoring for bleeding. b) Stand to client's side so cranial side corresponds to non-dominant hand. Press non-dominant hand firmly into abdominal wall just above symphysis pubis. Pass open dominant hand behind the fundus and bend fundus over lower hand. Compress for 5-20 minutes, then gradually attempt to release, monitoring for bleeding. c) Stand to client's side so cranial side corresponds to dominant hand. Press non-dominant hand firmly into abdominal wall just above symphysis pubis. Pass open dominant hand behind the fundus and bend fundus over lower hand. Compress for 5-20 minutes, then gradually attempt to release, monitoring for bleeding. d) Stand to client's side so cranial side corresponds to non-dominant hand. Press non-dominant hand firmly into abdominal wall just above symphysis pubis. Place dominant hand on the fundus and push firmly posteriorly for 5-20 minutes, then gradually attempt to release, monitoring for bleeding.

# ``` 205 . Which of the following is not appropriate care of the umbilical cord? a) Collecting a cord blood sample (while the cord is still pulsating) when the client is Rh negative. b) Waiting until the cord has stopped pulsing before clamping and cutting. c) Evaluating the cord for true knots or pseudoknots. d) Evaluating the cord for number of vessels. Normal is 2 arteries and 1 vein.

206 . Which best describes how to inject Lidocaine prior to suturing? a) Insert the needle along the length of the wound and then inject medication as you slowly withdraw the needle. Remove the needle and insert again in another area and repeat the injection procedure as needed. Check for numbness before suturing. b) Insert the needle along the length of the wound, aspirate, and then inject medication as you slowly withdraw the needle. Without pulling the tip out, redirect the tip to another area where sutures will enter, insert again and repeat aspiration and injection as you withdraw the needle. Repeat as needed. Check for numbness before suturing. c) Insert the needle along the length of the wound, aspirate, and then inject medication as you slowly withdraw the needle. Remove the needle and insert again in another area and repeat the injection procedure as needed. Check for numbness before suturing. d) Insert the needle along the length of the wound, and then inject medication as you slowly withdraw the needle. Without pulling the tip out, redirect the tip to another area where sutures will enter, insert again and repeat injection as you withdraw the needle. Repeat as needed. Check for numbness before suturing.

207 . You're performing active management of the third stage with Nevada, who is nursing her neonate. Bleeding is moderate, and the uterus is contracting well. As you feel the cord rapidly lengthening, Nevada suddenly shows signs of shock, though visible bleeding has not increased. You feel her abdomen to check for ballooning of the uterus, but instead feel a funnel-like depression. You insert your hand to confirm the location of the placenta and to check for concealed clots, and feel a soft tumor-like object filling the vaginal orifice. You immediately tell your assistant to call an ambulance and tell them you suspect what? a) Placental abruption. b) Uterine inversion. c) Postpartum hemorrhage. d) Placenta accreta or percreta.

208 . What should a newly postpartum mother's sleep patterns ideally look like in the first week or so, with a healthy breastfeeding baby who's producing the expected number of dirty and wet diapers? a) Overnight, sleeping between feeds but remaining awake to check on baby's wellbeing and latch/feeding throughout a feed. Napping during the day if she happens to do so! b) Overnight, sleeping for as long as the baby will allow her to, and sleeping during feeds once she's got the latch right. Naps during the day if she has the time and is tired. c) Overnight, no longer than a 6-hour stretch between feeds. She should aim for a total of 8 hours each day, napping during the day if she has a shortfall overnight. d) Overnight, sleeping 2-3 hours at a time between feeds, and during them if she feels she can safely/effectively do so. Building in naps during the day to ensure she gets as much sleep as possible.

209 . When examining a neonate's skin color, which of these statements is inaccurate? a) Pallor: this is a sign of peripheral vasoconstriction, hypovolemia, birth asphyxia, acute heart failure or shock. Transport. b) Yellow: this is a sign of jaundice. This is physiologic at birth, and often persists for the first several days, especially if the infant is exclusively breastfed. c) Ruddy: this is a sign of neonatal polycythemia. Transport. d) Slate gray: this is a sign of a hypovolemic baby, or one with peripheral vascular constriction or abnormal hgb. Transport.

210 . Which of the following helps regulate a neonate's temperature, respiratory rate and heart rate, promotes bonding, relaxation and gut colonization with beneficial bacteria? a) The hypothalamus. b) Swaddling. c) Skin-to-skin contact. d) The pituitary gland.

211 . Which of the following observations of a male baby born at 41.3 weeks would not lead you to think there might be a discrepancy in dates? a) Testes not fully descended b) Abundant lanugo c) Full areolas, 5-10 mm buds d) No rugae present

212 . What is a urogenital sinus? a) The rhythm at which the pulse is felt in the urogenital area when the bladder is full. b) The cavity through which the vagina and the urethra pass before their orifices. c) There is only one, shared, opening for the vagina and the urethra. d) The vagina and urethral orifices are swapped anteroposteriorly from normal.

213 . You're palpating and listening to a neonate's abdomen. Which of these would be an abnormal finding? a) No bowel sounds 15 minutes after birth b) Abdomen is rounded and symmetrical c) Bowel sounds present 45 minutes after birth d) Scaphoid abdomen

214 . You're about to suture Nix's second degree tear, but you're going to inject lidocaine first. Which of the following is not correct? a) You should use the smallest possible dose to achieve the desired effect. b) Ensure Nix has no known hypersensitivity to Lidocaine or amide type local anesthetics, and monitor them for signs of adverse reactions once injected (e.g. respiratory distress). Administer epinephrine if so. c) The maximum safe adult dose of 1% Lidocaine is 30 ml/300 mg, but the maximum safe adult dose of 1% Lidocaine with epinephrine is 50 ml/500 mg. d) Aspirate needle before injecting to prevent injection into muscle.

215 . You're assisting Noura at the birth of her third child. She has a BMI of 32.7, and you struggled to palpate the fetus well. You know it is in longitudinal lie and is cephalic, but nothing else. She's declined vaginal checks. As the presenting part begins to crown, your see fetal mouth and nose, with the nose anterior of the mouth. What do you do? a) The fetus is mentum anterior. Help maintain full extension by pressing on the sinciput. b) The fetus is mentum posterior and cannot safely be born vaginally. Transport. c) The fetus is mentum posterior. Help maintain full extension by pressing on the sinciput. d) The fetus is mentum anterior and cannot safely be born vaginally. Transport.

216 . Natsume has been following your recommendations for managing a complication of labor, and has recently been leaning forwards in the birth pool with her back straight, standing and lifting her belly at the level of the navel during contractions, and is now in a semi-reclining position. What complication is she experiencing? a) Maternal exhaustion. b) A pendulous abdomen is inhibiting fetal descent. c) Asynclitic fetal position. d) Deep transverse arrest.

217 . Which of the following is not a situation in which an episiotomy might be indicated? a) If the client has poor tissue integrity that you believe is at high risk of extensive lacerations. b) If there is a need for immediate birth due to risk of anoxia or fetal hemorrhage and you believe an episiotomy will speed up delivery. c) If there is a dystocia at birth and you cannot get your hand(s) in to perform the maneuvers required to resolve the situation. d) If the client is going to tear anyway, as an episiotomy is easier to repair than a laceration.

218 . Which of the following is not an indication for pathology examination of the placenta? a) Stillbirth. b) Multiple calcifications seen on the placenta. c) Neonatal neurologic problems. d) Maternal infection antepartum, such as suspected TORCH.

219 . Naomi has been laboring well for about 6 hours since you arrived, and is beginning to feel the urge to push, but she cries out whenever she tries, and tells you there's something wrong. She asks for a vaginal exam, and you find an anterior lip pinched between the pelvis and the fetal head. You discuss possible ways to resolve this with her. Which of these is not one of the things you discuss? a) You could manually massage the lip, possibly with evening primrose oil or with ice in a surgical glove. b) Although it might become difficult, refraining from pushing for a while could allow it to resolve spontaneously. You can help support her through this in various ways. c) You could push the cervix behind the descending head, though this can be quite uncomfortable. d) Position changes, but avoiding anything that reduces the pressure of the fetal head on the cervix, such as knees-chest or inversions.

220 . Nawal is about to deliver with a fetus in face presentation. You're preparing mentally for complications and what to do about them. Which is not high in your mind because there's no increased risk of it with face presentation? a) There may be tracheal edema, which would make intubation difficult if resuscitation is required. b) There may be cephalohematoma. Observe carefully for signs of jaundice, as risk of this is increased. Discuss Vitamin K with parents. Otherwise, this will generally resolve in a few weeks or months without any intervention required. c) The face may have extensive bruising and swelling. Topical arnica cream will help. Swelling will fade in 1-2 days, and bruising in 1-2 weeks. d) There may be breathing difficulties. Prepare for resuscitation.

221 . Nevaeh (G3P2002) has been in active labor for 2 hours and is beginning to feel the urge to push. You ask her to empty her bladder before she does so, and she then shouts to you that her waters broke, and there's something coming out her vagina. She says she thinks it's the cord. What do you do? a) Tell Nevaeh not to touch the cord and to lie down. Prop her hips up with pillows, telling your assistant to call an ambulance while you do, and to listen to FHT continuously. Lift the fetal head into the iliac fossa opposite the prolapsed cord. If FHT are non-reassuring, remove your hand so Nevaeh can get into a new position and immediately replace it. Only remove your hand permanently once the paramedics have arrived and taken over her care. b) Ask your assistant to call an ambulance and have Nevaeh get into a squat. Since she is G3 with two previous vaginal births, she can birth the fetus fast enough that there is very little risk of any compromise, but you want the ambulance there just in case. Coach her to push long and hard, and assist with traction. An episiotomy might be required to hasten birth. c) Tell Nevaeh to carefully place the prolapsed cord into her vagina while you call for an ambulance. Have her lie on the bed and check FHT. If they are non-reassuring, prop her hips up with pillows and place your hand in her vagina and lift the fetal head far enough to relieve compression of the cord. d) Get Nevaeh off the toilet and into deep knee-chest. Tell her not to touch the cord, and tell your assistant to call an ambulance and take continuous FHT. Insert your hand into her vagina and lift the fetal head, ideally into the iliac fossa on the side opposite where the cord is prolapsed. If FHT are non-reassuring, have Nevaeh change position without removing your hand. Help her breathe through contractions and not bear down. If she struggles with this, have your assistant give her a uterine-relaxant such as motherwort or lobelia. Do not remove your hand until the OB is performing the cesarean and tells you he is ready for you to do so.

222 . When performing a neonatal exam, you've finished checking reflexes and then change gloves and insert a finger into the newborn's mouth, pause for a couple of seconds, and then cover one and then the other naris. Why? a) You're checking for cleft palate. b) You're checking for patent nostrils. c) You're checking for tongue tie. d) You're checking that the neonate can suck well.

223 . Nicola has been pushing for 50 minutes, and the fetus has been crowning for 20. FHT show reactivity to scalp stimulation and are 110-120. Nicola decided not to follow your suggestion of touching the fetal head, and has gone from pushing effectively to rearing backwards during contractions. Which might be the most effective management technique? a) Transporting Nicola so she can be given Pitocin to augment her labor. b) Giving Nicola and her partner the opportunity to discuss any fears they may have. c) Telling Nicola to move to a different position so that you can better see what's going on. d) Attempting to manually readjust fetal position to LOA.

224 . You've been monitoring and supporting Nan (G3P2002) through labor, and she's now in the second stage. Her baby is just crowning when you look up to see that Nan is very pale, and realize her skin is cold and clammy. She's clearly tachypneic, and looks visibly distressed - something you've not seen from Nan at her other 2 births. You quickly check her BP, and discover that it's fallen from around 110/76 to 66/42. Which of the following will you do first? a) Elevate Nan's torso and legs and keep her warm with a blanket. She appears to be in shock. b) Encourage Nan's husband to begin nipple stimulation on her. She seems to have a hidden hemorrhage. c) Check FHT. If they are non-reassuring, use forceps or a vacuum extractor to deliver the fetus. d) Call an ambulance. Nan appears to be in hemorrhagic shock.

225 . Which of the following does not have a negative correlation between amount and gestational age? a) Amniotic fluid volume b) Vernix c) Lanugo d) Desquamation

226 . When auscultating a neonate's chest, which of the following is a normal finding? a) Respiratory rate 25 breaths per minute b) Heart rate 95 bpm c) Respiratory rate 55 breaths per minute d) Heart rate 190 bpm

227 . Which of the following is not a step you should take when manually removing the placenta? a) Find the plane of cleavage or an area already separated, and insinuate fingers between placenta and uterine wall, fingers widely splayed. Rotate hand to separate other areas. Once fully separated, grasp the placenta and gently remove your hand between contractions. b) Get your fingertips under the membranes (if possible) and follow to the lowermost edge of the placenta. You can also try to navigate around the membranes once you reach the placenta if you can't do this before, and it's possible to remove it without being outside the membranes, but this is much harder. c) Form hand into a cone and insert, avoiding contact with perineum as much as possible. Using your external hand to pull the cord taught, follow it with your internal hand. d) Wash hands and arm, and don a long sterile glove on your examining hand. Apply sterile water-based lubricant.

228 . You're looking at a newborn's finger nails. The baby was 37.5 weeks gestation, and was born precipitously after the mother's membranes ruptured whilst she was having a bowel movement. Which of these observations is not accurate? a) Koilonychia (spoon-shaped nails) could indicate a genetic disorder, but they are often a normal variant and typically resolve spontaneously. b) A green/yellow tint to nails suggests that meconium was passed in utero. If vernix is not also stained, the timing of this was probably between 6 and 12 hours before birth. c) Ingrown fingernails are a normal variant in a newborn, and the situation is spontaneously corrected by 2-3 weeks. d) Nails extending 1-2 mm beyond the nail bed are indicative of a possible discrepancy in dates.

229 . Which of the following if not a sign of placental separation? a) A gush of blood. b) Lengthening of cord. c) Contractions resume, with or without an urge to push. d) Drop in maternal BP.

230 . Which of the following is not a sign of dehydration in a neonate? a) Sunken fontanelles. b) Dry, cracked lips or dry mucous membranes. c) Skin on dorsal side of hand does not immediately return to normal when pinched. d) Oliguria is not present.

231 . Which of the following is not a correct definition regarding FHR? a) Acceleration: an increase in FHR of at least 15 bpm above baseline within 30 seconds, lasting between 15 seconds and 2 minutes. b) Bradycardia: a baseline (i.e. for 10 minutes or longer) of 160 bpm or more c) Reactivity: a type of variability that directly results from fetal movement or stimulation. Minimal is a peak to trough ≤5 bpm, moderate is peak to trough or 6-25 bpm, and marked is >25 bpm. d) Variable deceleration: a decrease in FHR below baseline of at least 15 bpm within 30 seconds, lasting between 15 seconds and 2 minutes, and displaying no consistent pattern or timing in relationship to uterine activity.

232 . Which of the following is not a way in which a midwife would normally provide physical support to aid relaxation or as a comfort measure? a) Encouraging client to stay in the same position for as long as possible before switching to another. b) Using cold packs, hot packs, a warm shower or warm bath. c) Using a TENS machine or having the client hold combs. d) A double hip squeeze, counterpressure, touch/massage or acupressure.

233 . The last time you checked Nani's vital signs, about 30 minutes before birth, her blood pressure was 120/82, pulse was 110, temperature was 98.0, and respiratory rate was 24. Now, an hour after birth, her legs are shaking uncontrollably, she's lost around 200 ml of blood, and she's feeling very sleepy. Her blood pressure is down to 98/66, her pulse is down to 84, temperature has gone up to 98.4, and her respiratory rate has dropped to 18. What's wrong in this situation? a) Nani has signs of a postpartum hemorrhage. b) Nani has signs of a uterine infection. c) You didn't take vital signs for too long. d) Nani has signs of silent postpartum preeclampsia.

234 . When performing the newborn exam, you notice the sclera of the eyes is yellow-tinged. Which of these statements is not accurate? a) Visible jaundice at birth is pathological. The neonate needs transferring to the doctor. Collect cord blood samples in red- and purple-topped tubes so baseline bilirubin can be obtained. b) There is the possibility of the need for an exchange transfusion in a neonate with severe jaundice. c) Phototherapy allows excretion of unconjugated bilirubin, and may make bilirubin less toxic before serum levels fall. d) Yellowing of sclera at birth is a variation of normal, and is not a sign of jaundice at this stage. It will fade spontaneously over the first 24-48 hours.

235 . Your client has just told you she's very worried because she thinks she has a uterine prolapse, and you're assessing whether she does and, if so, the degree so you can determine whether homeopathic sepia 200C, gently pushing the cervix back up, a pessary or referral to a pelvic floor therapist or physician is most appropriate. Which of these is not an accurate description of a stage of prolapse? a) Fourth degree: Procidentia (complete eversion of the uterus). b) Second degree: The cervix drops to the introitus. c) Third degree: The cervix descends outside the introitus. d) First degree: The cervix is swollen, but has not dropped from its original location.

236 . When Natalie arrives in labor, you palpate her abdomen and feel an obvious fetal spine on Natalie's left side and think you feel a well-engaged head in the pelvis, but cannot identify a cephalic prominence. During the vaginal exam, you discover that Natalie's cervix is dilated to 4 cm, and you can feel the fetal head with the posterior fontanel just anterior and left-lateral of central. This is the lowermost part, and is level with the ischial spines, and you can just feel the sagittal suture running in an oblique diameter posteriorly and right laterally. Which best describes the fetal lie, presentation, position and descent? a) The fetal lie is longitudinal, with cephalic presentation, and with LOT position. The head is asynclitic, and station is 0. b) The fetal lie is longitudinal, with cephalic presentation, and with LOA position. The head is synclitic, and station is 0. c) The fetal lie is longitudinal, with cephalic presentation, and with LOT position. The head is synclitic, and station is 0. d) The fetal lie is longitudinal, with cephalic presentation, and with LOA position. The head is asynclitic, and station is 0.

237 . Norma's range of normal vital signs during the third trimester have been: Temperature: 97.2 to 98.1, BP 116/76 to 122/84, pulse: 76-86, respiratory rate 16-22. At your first check during labor, Norma's vital signs are: Temperature: 97.8, BP 124/88, pulse 90, respiratory rate 26. What do you do? a) Norma is heading towards preeclampsia, and needs more frequent monitoring of vital signs. A transfer may soon become necessary. b) Norma may be having an asthma attack. Check her records for this diagnosis, and recommend a rescue inhaler if she has one. c) Norma is showing signs of an infection. You should discuss with her the option of starting IV antibiotics, mentioning the possibility of a need of transfer later if she decides not to have them. d) Norma may simply be nervous and excited about your arrival. Help settle her into the situation and then recheck.

238 . You're performing a newborn exam on a baby just after the Golden Hour has ended, and so the baby is very calm and relaxed. You're getting close to the end of the exam, and have just checked genitalia. Which of the following observations that you might have just had is a sign that the baby could have an imperforate anus? a) Lack of meconium bowel movement within the first 24 hours. b) Anus positioned close to the vagina c) Passage of meconium from an unconfirmed location. d) Swollen stomach

239 . At a 36-week home visit, you're setting up a room ready for water birth. Which of the following is not on your 'to do' list? a) Filling the tub and covering it, ensuring the cover fits snuggly all 'round. b) Reminding yourself to check your birth bag contains waterproof gowns, long gloves, a waterproof doppler and cushioned kneeling mats. c) Check the hose to be used for filling it is clean and that it can be well-connected to the water outlet. d) Check the pool for leaks, damage to the pool liner or signs that it was not thoroughly cleaned after the last use (if it has been used before).

240 . Which of the following scenarios (with no known issues with breastfeeding or the baby) is not an appropriate feeding pattern? a) Sucking for several seconds at a time until letdown is achieved, then pausing to swallow every couple of seconds. b) 2-4 hours between feeds with 10-20 minutes on the first breast and the second offered, alternating which breast is offered first. c) 6-8 hours between two feeds in the first 24 hours. d) Every 3 hours for 10 minutes each side.