NARM Practice Exam 600 Questions - (121-270) Prenatal Flashcards
121 . Which of the following would not cause hematocrit to be reduced?
a) Hemorrhage, with the blood draw done immediately after it occurred.
b) Vitamin or mineral deficiency (e.g. iron, B12, B6)
c) Hemolysis
d) Overhydration
A
122 . You’re attempting to assess fetal flexion by performing Leopold’s Maneuvers. Which of these statements is not true?
a) If the cephalic prominence is on the same side as the fetal back, the fetal head is extended, and the fetus has either brow or face presentation.
b) If no cephalic prominence is felt, there is neither flexion nor extension, and the fetus is in military position.
c) If the cephalic prominence is on the same side as the small parts, the fetus is well-flexed and the fetus is in vertex position.
d) The third maneuver (or Pawlick’s grip) is used to ascertain fetal flexion, whereby the thumb and fingers of the dominant hand are placed just above the pubic symphysis and the presenting part is grasped.
D
123 . Melissa admits to you at 16 weeks that she’s started smoking again, and asks what the risks to the baby are. You tell her that it exposes the baby to toxins such as lead, cadmium, cyanide, nicotine and carbon monoxide, that the baby’s blood flow is reduced, limiting the delivery of oxygen and nutrients, resulting in impaired growth and development. It significantly increases the risk of miscarriage, stillbirth, abnormalities with the placenta, IUGR and neonatal death. Which of the following did you forget?
a) Post term delivery
b) Low birth weight
c) Macrosomia
d) Preterm delivery
D
124 . Molly called you last week to enquire about your services, as she’d just discovered that she was pregnant. Today, she calls you to tell you she has menstrual-like cramps, spotting, nausea, and, probably unrelated, pain in her shoulder. Since she’s not yet a client, you explain that you can’t treat her, but you feel compelled to tell her what?
a) She’s having a threatened miscarriage. She should wait to see what happens, as there’s nothing that can be done at this stage.
b) She is having an inevitable spontaneous abortion. She can wait to pass the products of conception naturally or see a physician for uterine evacuation.
c) She may be experiencing an ectopic pregnancy, and should see a physician as soon as possible.
d) She’s showing symptoms of appendicitis, and should see her primary care provider as soon as possible.
C
125 . At 28 weeks, Lydia complained of varicose veins, and you told her of various ways she could help mitigate them. Lydia chose to exercise more, has been trying to avoid standing for prolonged periods of time, and has been taking Vitamin E. She decided not to use compression socks because it was too hot. Today, you want to go through signs and symptoms of thrombophlebitis with her. Which of these will you not tell her to look out for?
a) Fever, racing heart, severe pain in the leg that starts suddenly.
b) Heat, pain, swelling and/or a knot or cord you can feel (but don’t massage it or poke it too much!)
c) Swelling across your body, pain if you touch one area of the calf, tenderness along the length of the vein.
d) Flex your foot (lift towards your leg) to see if there’s sharp pain in the leg. (Think of embolization.)
D
126 . At 29 weeks, Laocadia calls you to report bleeding. She had intercourse and then a little cramping, and is worried she’s starting labor. Which one of these should you avoid doing?
a) Reassure her that it’s very unlikely she’s in labor - a little cramping after intercourse is normal, and the bleeding is probably from a sensitive cervix or a polyp or fibroid.
b) Ask Laocadia to come in so you can take her vital signs and listen to the baby’s heart.
c) Do a vaginal exam to check for cervical change so you can determine the appropriate care.
d) Refer her to a physician to hopefully rule out premature labor, placenta previa or placental abruption.
C
127 . Kamille is 36 weeks pregnant, and has moderate pitting edema in both of her lower legs. She reports that it tends to worsen during the day and is quite uncomfortable by bedtime. What do you do?
a) Explain that this can be an early sign of preeclampsia, and Kamille needs to keep an eye on it. If it spreads to her hands and face, she should call you immediately.
b) Explain that while this is no cause for concern, Kamille can make changes to help ease the symptoms, including wearing compression socks, elevating her feet, adding salt ‘to taste’ to her food, hydrating well and eating a healthful diet with plenty of protein.
c) Explain that this is due to fluid from the blood seeping into spaces around cells, reducing the blood volume, which can cause problems like premature labor.
d) Explain that this is normal and is because of hormonal changes, and it shows that her blood volume is well-expanded.
B
128 . Which of the following has inaccurate information on possible methods for stimulating the start of labor in a post-dates client (with intact membranes)?
a) Having the client take: Castrol oil, blue/black cohosh, red raspberry leaf, evening primrose oil (orally or internally), cimicifuga, and/or caulophyllum.
b) Chiropractic adjustment or acupuncture.
c) Stripping membranes (using sterile technique), amniotomy (with a fetus that is well-engaged) or attempting to reposition a malpositioned fetus.
d) Sexual intercourse (unprotected), nipple stimulation, and discussing emotional blockages that may be interfering.
A
129 . Which of these FHR is outside the normal range?
a) 162 bpm at 10 weeks
b) 148 bpm at 16 weeks
c) 134 bpm at 36 weeks
d) 170 bpm at 28 weeks
D
130 . You’re explaining to your student how to identify breech presentation. Which of the following is the best advice when the student is moving through the Leopold maneuvers?
a) If the pregnant person reports fetal movement near the cervix or a hard ball in the ribs, it is likely that the fetus is breech.
b) Listen for the fetal heart tones. If they’re high in the abdomen, it is likely that the fetus is breech.
c) Palpate gently but deep into the abdomen so that you can feel the fetus well.
d) Never assume that a fetus is cephalic. Keep searching until you are certain you have felt a head - a hard ball that moves independently of the trunk. If you can’t find it, you can’t be certain of fetal position.
D
131 . At her 34-week appointment with Lavender, you decide to do a fluid thrill test, and tap on one side of the uterus and feel for a fluid thrill on the other side. Which scenario led you to perform this test?
a) Positive GTT results.
b) Placental souffle heard in the lower part of the uterus.
c) Difficult to palpate fetus. Fundal height 37 cm.
d) Fetal head felt in the fundus, but unable to determine if fetal buttocks or legs are presenting.
C
132 . Lindy’s fundal height measurements for the last few appointments have been: 20 weeks: 20 cm, 24 weeks: 25 cm, 28 weeks: 30 cm, 30 weeks: 33 cm. When you measure her today, at 32 weeks and 4 days, fundal height is 36 cm. Which of these is not a likely explanation for the high fundal height measurements?
a) Gestational diabetes
b) Incorrect dates
c) Polyhydramnios
d) Multiples
B
133 . Landry tells you she’s been feeling a lot of tingling and numbness in her thumb, index finger and middle finger. You ask her to bend her wrists and put her hands together, back-to-back. Within 30 seconds, she tells you she feels the tingling and numbness and also discomfort. Which of these is not a good recommendation for Landry?
a) When doing nerve gliding exercises, apply crushed ice to the hand for 20 minutes prior to the exercise, and apply heat to the hand afterwards.
b) Wear a wrist splint at night to place the wrist in a neutral position
c) Drink skullcap and take a B-complex supplement
d) Hand and wrist exercises, like fist to stop sign, fist to fan, thumb touches and gentle wrist stretches.
A
134 . At a prenatal appointment, you ask Judith to look at your pen point as you hold it about 2 feet from her face. You then move it towards her nose, carefully watching her eyes. What are you doing, and why?
a) Watching for the convergence of the eyes and contraction of pupils as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
b) Watching for the divergence of the eyes and dilation of pupils as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
c) Watching for the convergence of the eyes and dilation of irises as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
d) Watching for the divergence of the eyes and contraction of irises as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
A
135 . Which of the following would not be a reasonable possible interpretation of cloudy urine?
a) Protein is present in the sample
b) Holding for long periods of time, leading to formation of sediment
c) Vaginal discharge is present in the sample
d) Overhydration
D
136 . Leanne has symptoms of a vaginal yeast infection, but has declined allopathic treatment. Which of these would you not recommend to her?
a) Taking garlic (in food, ideally not heavily cooked, or in tablet or capsule form), or even inserting a whole, un-nicked clove vaginally may help. Remove a clove from the vagina if it causes a burning sensation, and change 3 times a day if not.
b) Wear cotton underwear, or no underwear at all. If wearing a pantyliner, get a breathable one and change it regularly.
c) Try inserting boric acid suppositories, which prevent candida fungi from growing, or taking oral fluconazole.
d) Take a high-quality probiotic such as Lactobacillus rhamnosus or Lactobacillus acidophilus.
C
137 . You’ve carefully researched and written practice protocols, including those for emergency transfer of care. Today, one of your favorite clients is in a situation that would normally trigger emergency transfer, but she begs you to try a few more things before activating the protocol. What do you do?
a) If you list all the risks and benefits of the decision and your client gives informed consent, you can choose not to follow the protocols on this occasion.
b) Follow your protocol. You used your best clinical judgement to write the protocols without emotion influencing them, and so the safest thing to do for your client is to follow them now.
c) Follow your protocol. You would get a bad reputation if you displayed favoritism to one client.
d) If you feel that you can try the extra steps before transfer without putting the client or her baby at significant risk, you should follow her request.
B
138 . You’re practicing in a state where midwives can attend births from 37.0 weeks. Moira (G1P0000) calls you at 36.5 weeks to tell you she’s had menstrual-like cramps on and off for a couple of hours, and had diarrhea earlier today. You suspect she may be in early labor. What should you do?
a) Suggest that Moira drink plenty of water, take a warm bath with lavender oil and epsom salts, and then lie down on her left side.
b) Since this is Moira’s first labor, it’s likely it will take a long time, so you decide to let it take its course. At worst, the baby will be born at 36.6, and no-one will care about you attending a birth 1 day early!
c) Suggest that Moira drink some cayenne tea and then go for a walk for an hour or so.
d) Suggest that Moira take a Benadryl and some calcium and then try to sleep.
A
139 . When Jaqueline’s baby is born, she comments on the shape of his head, worried that he might be brain damaged. Which is most accurate?
a) During labor and birth, the baby’s head normally ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. In fact, the bones of a baby’s skull are designed to do this: they can overlap slightly, making the head smaller in certain places so that it can better fit through the pelvis.
b) During labor and birth, the baby’s head often ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. It’s called a caput succedaneum, and will disappear in a couple of days with no lasting damage.
c) During labor and birth, the baby’s head normally ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. In fact, the bones of a baby’s skull are designed to do this: they can move slightly without having any negative impact on the brain.
d) During labor and birth, the baby’s head normally ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. In fact, the bones of a baby’s skull are designed to do this: they can separate slightly as they are pushed out of place by the bony pelvis.
A
140 . Janiya, 20 weeks pregnant, recently moved to the USA and just called to enquire about hiring you as her midwife. What is one concern about her care that you want to address the first time you meet with her, and then revisit periodically?
a) What social support system she has in place.
b) Whether she’s in the country legally.
c) Whether she can afford to pay you.
d) What prenatal care she had before moving to the US.
A
141 . Jo sheepishly tells you she’s been craving laundry detergent, and has had to ask her partner to do all the laundry so she can avoid temptation. What should you say to Jo?
a) Explain that this is fairly common in pregnancy and is called ‘pica’. It’s not always a craving for laundry detergent, but for any non-nutritive item, like ice chips, dirt or clay. Be non-judgmental in your response, but agree that she is right that she needs to fight this temptation. It’s not known for certain, but it’s thought that pica is caused by something missing in the diet, such as iron or other minerals. Discuss how you might address this with diet, supplements and possibly testing to help identify the source of the problem.
b) Explain that this is called ‘pica’, and it’s very common, where people crave non-food items like dirt. Tell Jo what effect laundry detergent might have on her and on the baby and stress the importance that she continue to fight the temptation.
c) Without any judgement, tell Jo that this is called ‘pica’ and is a sign that she’s not getting enough iron in her diet. Explore with her ways in which she could increase iron intake, including with diet, cooking in cast iron pans and/or supplements such as floradix.
d) Tell Jo this is bordering on child abuse, as the laundry detergent could kill her unborn child, and make it clear to her that if she admits to you that she’s followed through on her craving, you’ll have no choice but to call CPS to help protect her baby.
A
142 . Which of these statements about estimating fetal weight is not accurate?
a) Research shows that weight estimates from palpation are generally overestimated.
b) Research shows that weight estimates from sonograms are generally underestimated.
c) Fetal weight estimation needs considerable ‘calibration’, wherein the provider records estimated weights and then weighs the neonates in order to determine accuracy, and updates methods as appropriate.
d) Fetal weight estimation is least accurate for macrosomic babies.
D
143 . At 38 weeks, you discover that Lee’s fetus is ROP. Which of these is not a technique you should encourage her to try in order to help with rotation to the anterior?
a) Straddle an armless chair, facing its back, and rest your arms on the chair’s back. Move your bottom back to the edge of the seat and lean forwards so your belly hangs low. Relax your abdominal muscles and maintain this for 20 minutes 4 to 6 times a day.
b) See a chiropractor for an adjustment.
c) Do pelvic rocks (cat-cows) for 10 minutes 6 to 8 times a day.
d) Lie on your back, head down, on a plank or ironing board propped up on a sofa. Do this for up to 20 minutes 1-3 times a day.
D
144 . Which of these are not all symptoms or signs of a uterine rupture?
a) Abrupt bradycardia/recurrent decelerations that become deeper, easily palpable fetus
b) Sudden loss of fetal station, vaginal bleeding
c) Uterine tachysystole
d) Maternal anxiety, abdominal pain/uterine guarding
C
145 . Which of these includes an item that is not a symptom of a rectocele?
a) Constipation or the need to press against the vagina or perineum to have a bowel movement
b) The urge to have multiple bowel movements each day.
c) Dyspareunia or a sense of fullness in the vagina.
d) Fecal incontinence or diarrhea
D
146 . At 10 weeks, Linore calls you to tell you she has vaginal bleeding and worries she’s having a miscarriage. Which of these is not an alternative diagnosis that springs to your mind?
a) Vaginal infection
b) Fibroids
c) Placenta previa with cervical change
d) Subchorionic hemorrhage
C
147 . When auscultating Kataleya’s lungs, you’re listening to the same area on the left and right lung to be able to compare the sounds you hear. When auscultating posteriorly, you listen to left and right interscapular spaces. You notice that breath sounds on the right are at a higher pitch, are louder, that there’s equal inspiration and expiration intensity, and that there’s a noticeable pause in the sounds between inspiration and expiration. What’s causing this difference?
a) Kataleya has a partial blockage on the right, narrowing the airways there.
b) On the left, you’re auscultating heart sounds and lung tissue, whereas on the right you’re only auscultating lung tissue.
c) Kataleya has early bronchitis, currently only detectable on the right.
d) On the right, you’re auscultating the tracheobronchial tree and not lung tissue.
D
148 . You’ve asked Marge to do daily kick counts, timing how long it takes to feel 10 separate movements at approximately the same time every day, after a meal. Today, at 41w6d, she calls you to tell you that the time it’s taken over the last 3 days has increased from 13 minutes to 21 minutes and now to 36 minutes. What is your recommendation?
a) A reduction in fetal movement is normal post term, and of no clinical concern. Continue expectant management.
b) Marge should be transferred to the hospital for an emergency cesarean section.
c) Marge should be referred for a biophysical profile to assess fetal wellbeing, as decreased fetal movement is strongly correlated with fetal demise, especially post term.
d) Although the time it’s taken to count 10 movements has increased, it’s still far less than an hour, and so there is no cause for concern. Continue expectant management.
C
149 . Kim has glucose in her urine, as shown on the dipstick test you just did, but no other signs or symptoms of diabetes. Which is not an appropriate suggestion for supporting her kidney health while you investigate further?
a) Beet juice and pumpkin seeds
b) Juniper
c) Nettle leaf infusion
d) Lemon juice and cranberry juice
B
150 . Li messages you at 14 weeks to tell you she’s been having lots of tension headaches, with moderate pain across the width of her head. She asks why she’s getting them and whether she should worry, and whether there’s anything she can do to help with them. Which isn’t a good response?
a) There are several possible causes, such as changes in eyesight, but what you’re describing isn’t a cause for concern. One thing that might help is taking acetaminophen or ibuprofen.
b) There are several possible causes, such as low blood sugar, but what you’re describing isn’t a cause for concern. It might improve if you eat a little food, often, and avoid caffeine, chocolate and sugar. x
c) There are several possible causes, such as changes in circulation, but what you’re describing isn’t a cause for concern. You may find that massage, yoga and chiropractic care help.
d) There are several possible causes, such as changes in hormone levels, but what you’re describing isn’t a cause for concern. One thing that might help is drinking hops, skullcap or chamomile tea.
A
151 . At 36 weeks, you ask Jess to describe her breasts, and she says her nipples are like dimples. You ask if you can take a look and see inverted nipples. What do you do?
a) Tell Jess that inverted nipples make breastfeeding far harder, but she might still be able to get it to work if she works hard. Talk to her about several things she could try, and tell her to buy in supplies including a pump, various bottles and nipple cream.
b) Tell Jess to start power-pumping as soon as the appointment is over and to do at least 4 hours a day of pumping, as this can help suck the nipples out, solving the problem.
c) Tell Jess that this is fairly common. Whilst it does make breastfeeding more challenging, there are many things that can be done to help make it possible. Talk through a couple and suggest supplies she should have for after the baby is born, including a breast pump and at least 1 kind of nipple shield.
d) Inverted nipples are the norm. Tell Jo everything looks perfect and you’re sure she’ll have a long and enjoyable breastfeeding journey.
C
152 . You’re discussing diet with Kailee, and ask her to keep a dietary log for 3 days this week. You remind her that she should be getting at least 8-10 g of protein each day, at least 2-3 quarts of water, about 2300 calories daily, should include iron-rich, calcium-rich and magnesium-rich foods, and should continue with her prenatal vitamin. What error have you made?
a) Kailee should not be consuming caffeine, so no coffee, black tea or chocolate.
b) Kailee should drink far more water - at least 6 quarts (1.5 gallons) daily.
c) Kailee should be consuming at least 4,000 calories each day, in nutrient-dense foods.
d) Kailee needs far more protein - around 80-100 g daily.
D
153 . What is cholestasis?
a) Insulin flow is suppressed or blocked, resulting in pancreatitis and release of an excess of insulin into the blood.
b) Thyroxine flow is suppressed or blocked, resulting in permanent damage to the thyroid gland and a reduction in the amount of thyroxine released into the blood.
c) Bile flow is suppressed or blocked, resulting in the destruction of the liver cell membranes by bile acids, releasing bile acids into the blood.
d) Lymph flow is suppressed or blocked, resulting in swollen lymph nodes and the release of lymph into the blood.
C
154 . Which description of pulse is normal?
a) 48 bpm
b) Strong
c) Bounding
d) Thready
B
155 . You’re telling Mackenzie how to do kick counts. Which of these do you not tell her?
a) Hiccups count as movements.
b) Count for an hour each day, after your biggest meal of the day.
c) You should feel 8-10 separate movements in the hour you’re counting for.
d) If two movements follow straight on the heels of one another, such as baby moving an arm and then immediately a leg, count only 1 movement for this.
A
156 . Which of the following descriptions of vaginal discharge would not cause you concern?
a) “It’s increased lately, and it’s thin and milky-white.”
b) “It’s increased a lot lately. I do have a bit of pain in the area, but I think it’s from urine burning me because it’s concentrated, as the area isn’t itchy - just a little painful.”
c) “It’s increased lately, and looks a bit lumpy, kind of like cottage cheese. It doesn’t smell bad, though.”
d) “It’s increased lately, and is a sort of greyish-green color. It’s kind of frothy-looking.”
A
157 . Jemima is 10 weeks pregnant when she calls you to tell you she needs an appointment with you as soon as possible because there’s something wrong with her. She feels utterly exhausted with very little physical exertion, and is very concerned. Which is the best response to Jemima?
a) In early pregnancy, maternal blood volume increases rapidly, which can cause moderate to severe anemia if nutrition isn’t great. Jemima should ensure she’s eating plenty of leafy greens, is getting B12 and folate, and is hydrating well.
b) You can’t talk to Jemima until she’s signed a contract with you.
c) In the second trimester, fatigue is often caused by inadequate caloric intake. Jemima should look carefully at her diet and should aim to identify ways in which she can make small changes that would increase her caloric intake whilst also ensuring she has a nutrient-dense diet.
d) In early pregnancy in particular, low energy levels are very common due to hormonal changes and the additional energy the body needs for pregnancy. It usually eases in the second trimester. It’s possible that something else is causing it, and you can talk about that in more detail at an appointment, but she shouldn’t be overly concerned.
D
158 . When are you likely to be able to pick up fetal heart tones with a doppler, and what is one factor that might affect this?
a) 13-15 weeks, affected by skill of the provider.
b) 11-13 weeks, affected by fetal size.
c) 10-12 weeks, affected by maternal BMI.
d) 12-14 weeks, affected by baby’s location.
C
159 . Leticia joined your practice at 28 weeks. At intake, you collect the following information: pulse: 76, respiratory rate 20, lungs and heart sound normal, no swollen lymph nodes, anatomy of head looks normal, mucous membranes are pink, pupillary reactions are normal, height 4’ 11”, weight 132 lb, weight gain during pregnancy reported as 10 lb, spine shows no visible kyphosis or scoliosis, no CVAT is elicited, no edema seen, fundal height is 25 cm, fetal heart tones are 132-136 bpm, and fetal lie is longitudinal. You’ve not yet received records from her OB in Mexico. What of the following is not a reasonable explanation for why fundal height is measuring low?
a) Genetically small infant that is normally grown
b) Transverse fetus
c) Fetal congenital anomaly, such as kidneys not functioning properly
d) Poor maternal weight gain
B
160 . Lucy has symptoms of heartburn and asks what she can do to ease them. Which of these is not a good recommendation for her?
a) Eat more slowly, and focus on fatty foods such as cheese and coconut oil
b) Eating smaller, more frequent meals that don’t include spicy food or foods you normally find hard to digest or that cause you gas
c) Digestive enzymes or papaya enzymes
d) Raising the head of the bed 4-6” for sleeping, and not lying down soon after eating
A
161 . At his wife’s appointment, Jason tells you he’s very concerned because they’ve just found out that his wife is A-, and he knows the baby’s blood crosses the placenta and so will mix with hers and could cause isoimmunization, which might make their baby very ill. What do you tell him?
a) The placenta is designed such that the baby’s and mother’s blood do not mix. Occasionally, some of baby’s blood does get into the mother’s bloodstream, such as if they’re in an accident or at birth, but there’s RhoGAM for that if they want it, and it’s unlikely that the current pregnancy would be affected even if there was blood transfer.
b) Although fetal blood and maternal blood do mix at the boundary of the placenta, there’s a very good filtration system there, and so Rhesus antigens don’t usually get into the maternal bloodstream. If they do, they have 72 hours to get RhoGAM, if they want it, which effectively prevents isoimmunization.
c) Although fetal blood and maternal blood do mix at the boundary of the placenta, there’s a very good filtration system there, and so Rhesus antibodies don’t usually get into the maternal bloodstream. If they do, they have 72 hours to get RhoGAM, if they want it, which effectively prevents isoimmunization.
d) The baby has a tiny blood volume, and so very little fetal blood gets into the maternal bloodstream unless there’s something like an accident or during birth. At these times, RhoGAM is recommended to reduce the risk of isoimmunization, but they could have RhoGAM earlier in pregnancy if they’re concerned.
A
162 . Which of the following is a normal change during pregnancy?
a) Clear breast discharge
b) Upper right quadrant pain
c) Severe nausea and vomiting
d) Lightheadedness with shoulder pain
A
163 . Your client, Jacinta, is Black. At a routine prenatal exam, you ask to look at her oral mucosa, and see brown spots that you don’t think were there the last time you checked, but you can’t be sure. What should you do?
a) Whilst physiologic oral pigmentation is relatively common and is more often seen in those with dark skin, there are many different causes for oral pigmentation, not all of which are benign. You should ask Jacinta about it and refer her to a physician for further evaluation if she’s uncertain.
b) You don’t want to offend Jacinta, or for her to think you’re racist, and so don’t want to mention this to her.
c) The color change indicates that Jacinta has been smoking, and so you need to have a very serious conversation with her about the risks of doing so, impressing upon her the importance of quitting immediately.
d) Oral pigmentation is physiologic in Black people, and is more common in women than in men. It’s also commonly triggered by pregnancy, and is not associated with any adverse effects.
A
164 . Which is a reasonable ‘rule of thumb’ for the odor of urine?
a) Sweet smell is normal. Unpleasant smell indicates an STI.
b) Sweet smell implies preeclampsia. Unpleasant smell implies candida.
c) Sweet smell suggests cystic fibrosis. Unpleasant smell is normal in pregnancy.
d) Sweet smell implies diabetes is likely. Unpleasant smell indicates infection of some kind.
D
165 . Kamala is 32 weeks pregnant, and has been having trouble sleeping. Which of these would you not tell her?
a) Half a dropperful of skullcap, valerian or hops may help.
b) Practicing deep relaxation can help, as can use of essential oils such as lavender.
c) Ensure you always lie on your back when trying to sleep, as this can rapidly decrease blood pressure so you can relax and sleep better.
d) Exercising can help. But not right before bed, as it can make the baby more active, increasing insomnia.
C
166 . What is the name of a bulging of the front wall of the lowermost few inches of the large intestine into the back wall of the vagina?
a) Cystocele
b) Rectocele
c) Enterocele
d) Uterocele
B
167 . At 36 weeks, Leonora tells you she’s had uncomfortable swelling in her ankles, and has been looking up remedies for it. She says she’s been elevating her legs, wearing compression socks, exercising more, and has started eating more protein and vegetables. You tell her these are all great tricks, but she still seems uneasy. On further probing, you find out that she’s worried she has preeclampsia because she read swelling is a sign of that. You reassure her it’s not preeclampsia, so she asks why she’s swollen. Which of these is the best explanation for uncomplicated edema?
a) In pregnancy, the flow of blood in the veins of your legs slows, and the pressure there increases slightly as your blood volume goes up. The higher estrogen levels you have during pregnancy, cause fluid to more easily leave the veins. The combination of a slow, higher pressure flow in more ‘leaky’ veins means that more fluid leaves the veins and is retained in the tissues that surround them, causing swelling.
b) In pregnancy, the flow of blood in the veins of your legs speeds up because of the increased volume, but the pressure there decreases because progesterone relaxes the blood vessels. The combination of a fast flow in low pressure veins means that more fluid leaves the veins and is retained in the tissues that surround them, causing swelling.
c) In pregnancy, you need additional salt for the growing placenta and baby, but most people don’t increase intake sufficiently, which causes an osmotic potential across the veins, drawing water into the surrounding tissues and causing swelling.
d) In pregnancy, you need far less salt, but people usually don’t cut their salt intake enough. The result is that your body holds on to more water to ‘balance out’ the salt.
A
168 . Which of these is not a test for clonus?
a) The client is asked to quickly flex their foot and then hold it there. If there is a series of pulses to the movement, this indicates clonus.
b) The quadriceps deep tendon reflex is triggered. If there is a repetitive vibratory contraction, this indicates clonus.
c) The client’s hands are placed together, backs touching and fingers pointing down. This is held for about a minute. If repeated oscillations are seen, this indicates clonus.
d) The client’s leg is extended and relaxed, and the patella is rapidly pushed towards the toes and held there. Rapid upward and downward movement of the patella indicates clonus.
C
169 . Which complication are these all risk factors for: Smoking, stress, poor nutrition, periodontal disease, UTI, genital tract infection, multiple gestation, prior preterm birth, prior cervical surgery?
a) Preeclampsia
b) Placental abruption
c) Systemic infection
d) Preterm birth
D
170 . Which of the following statements is accurate?
a) After vaginal delivery, a complete placenta previa is likely to require manual removal to avoid postpartum hemorrhage, as placenta accreta is commonly found in conjunction with placenta previa.
b) Bleeding due to placenta previa most commonly presents in the early second trimester due to Braxton Hicks contractions.
c) A pregnancy with a marginal placenta previa will inevitably separate as the cervix dilates, and there is a significant risk of cesarean.
d) Complete placenta previa discovered in the second trimester is likely to resolve itself before birth due to the growth of the lower uterine segment or the growth of the placenta in the direction of increased blood flow (i.e. towards the fundus).
C
171 . Lia is 34 years old, G2P1001, 20 weeks pregnant, and is planning a TOLAC. At her appointment today, she gives you the ultrasound report from her anatomy scan. The report notes a 4-chamber heart, 3-vessel cord, grade 0 anterior placenta with the lower margin 3 cm from the cervix, no anatomical abnormalities seen in other areas, and fetal measurements consistent with a fetus approximately 19 weeks 4 days gestational age. What on the report is concerning to you?
a) The fetus is measuring small for dates, and so you will want to order a repeat ultrasound in around 4 weeks to investigate the possibility of IUGR.
b) The placenta is low and anterior, probably implanted over the previous incision scar. This increases the risk of abnormal placentation, such as placenta accreta.
c) The placental margin is very close to the cervix, indicating there is significant risk of placenta previa, which is not compatible with vaginal birth.
d) The placenta is already a grade 0 at 20 weeks, which increases the risk of poor perfusion and resulting IUGR or fetal demise.
B
172 . Margarite’s pregnancy is now post term. At her recent appointments, you’ve seen the following: 40 weeks: fundal height 40 cm, head easily ballotable, FHT 134-146 with an acceleration heard in response to movement. 41 weeks: fundal height 40 cm, head slightly ballotable, FHT 130-144, with the peak heard following fetal movement. 42 weeks: fundal height 40.5cm, head well-engaged, FHT 136-148. Fetal movement in response to palpation, with corresponding rise in FHT. How do you interpret these results?
a) The fetus appears to be growing well, with lack of change in fundal height accounted for by the fact that the fetus is descending into the pelvis. FHT are reassuring.
b) The fetus does not appear to be growing well, and the FHR does not have good variability. You should continue listening to FHT until you hear a range of at least 30 bpm. If you don’t hear this, transfer care to an obstetrician.
c) The fetus does not appear to be growing much, but this is normal after 40 weeks because the placental grade has normally deteriorated significantly by then. FHT are reassuring.
d) The fetus does not appear to be growing at all, which is cause for concern. You should transfer care to a physician for emergency cesarean section.
A
173 . Which of the following is most accurate?
a) Passage through the intestinal tract is slowed during pregnancy due to oxytocin relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
b) Passage through the intestinal tract is slowed during pregnancy due to estrogen relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
c) Passage through the intestinal tract is slowed during pregnancy due to progesterone relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
d) Passage through the intestinal tract is slowed during pregnancy due to hCG relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
C
174 . Kelly’s urine stick test is positive for ketones. Which is not a reasonable explanation for this?
a) Kelly has gestational diabetes. In this case, glucosuria will also be seen
b) Kelly is malnourished, so her body is breaking down fats and protein for energy
c) Kelly is in labor. In this case, significant glucosuria and alkaline urinary pH are also likely to be seen
d) Kelly did not produce a ‘clean catch’ urine sample
D
175 . At 34 weeks, La-Keysha tells you she’s had several leg cramps in the last week or so, and some have been very painful. Which is not a good response?
a) Leg cramps are certainly no fun, but they’re very common and nothing to worry about. Make sure you’re drinking enough water and eating foods high in calcium, magnesium and potassium.
b) Leg cramps are often caused by electrolyte imbalances or low calcium and other minerals. Try taking 350 mg of magnesium before bed and drinking nettle leaf infusion.
c) If you think leg cramps hurt, just you wait until labor! One thing you can do is get new shoes that support your feet more than those ones do.
d) Leg cramps can be very painful. When you do get one, flex your foot like this, instead of pointing it out.
C
176 . Which of the following would not cause protein to be present in a urine sample?
a) Preeclampsia
b) Hypotension
c) UTI
d) Excessive exercise
B
177 . At her 28-week appointment, Laura complains of worsening constipation. Which of the following is not a good recommendation for her?
a) Drink at least 8 glasses of water a day, more if you’re outdoors a lot or are exercising, and take stimulant laxatives.
b) Take a walk every day, eat prunes or drink prune juice, and take stool softeners.
c) Eat a diet high in fiber like greens, celery or bran, and use glycerin suppositories.
d) Empty your bowels as soon as you feel an urge, and take bulk-forming laxatives.
A
178 . Which of the following is not a normal change during pregnancy?
a) Intensely itchy palms of hands and soles of feet.
b) Lumbar lordosis
c) Postcoital spotting
d) Increased vaginal discharge
A
179 . What is the normal pattern of blood pressure change during pregnancy?
a) A physiologic increase in the second trimester, caused by increased blood volume, and then a fall to approximately baseline in the third trimester due to dilation of blood vessels.
b) A pathologic decrease in the second trimester due to maternal anemia, and then a rise to approximately baseline due to blood volume increase.
c) A pathologic increase in the second trimester due to blood vessel constriction, and then a fall to approximately baseline due to vasodilation.
d) A physiologic decrease in the second trimester, caused by dilation of blood vessels, and then a rise to approximately baseline in third trimester, caused by blood volume expansion.
D
180 . At 34 weeks, Jillian’s urine dipstick test shows trace leukocytes, pH 7.5, specific gravity 1.005, trace protein, +1 glucose, and no ketones, bilirubin or urobilinogen. What is the most likely significance of the glucose result?
a) Preeclampsia
b) Gestational diabetes
c) Increased glucose filtration rate, high sugar intake or Vitamin C intake
d) Antibiotic intake
C
181 . Which blood pressure is not abnormal?
a) 136/60
b) 120/68
c) 150/92
d) 80/48
B
182 . At her 34-week appointment, you’re palpating Maxine’s abdomen when you feel a contraction building from her lower uterine segment up to the fundus. You ask Maxine about it, who says she can’t feel it very strongly, but she has noticed a few of them recently. Which of the following is the best course of action?
a) Consult an obstetrician because you suspect preterm labor. They may be able to provide medications to stall labor if you act quickly.
b) Tell Maxine that these ‘toning contractions’ are called Braxton Hicks and she’ll probably feel a lot more of them from now on. Explain that they’ll be more common when her bladder is full or, conversely, when she’s dehydrated, and exercise and bumpy car rides often trigger them too.
c) Consult with a chiropractor who is certified in the Webster Technique about whether an adjustment might help Maxine in such a way that the fetus might be better able to get into an optimal position.
d) Suggest that Maxine should pack her bag for the birth center and get the baby’s car seat in soon because this is a sign that she might go into labor sooner rather than later.
A
183 . Juli is 28, G3P2002, and had her intake appointment with you a couple of days ago at 37.1 weeks. Your physical assessment found nothing of note beyond mild edema in her ankles. Her urine dipstick showed trace protein. Her BP was 126/78, pulse was 76, and temperature was 97.5. Fundal height was 36 cm, with the fetus LOA and FHR 132-146. The OB panel is back, and there was nothing of significance. She’s A+. You’ve not yet obtained Juli’s records, as she says her OB’s is “being difficult” about releasing them. You’ve never had an issue with this OB before, so expect to receive records soon. That evening, Juli calls to tell you she’s in labor. How do you feel?
a) Very concerned. You haven’t seen prenatal records, and so have no proof she even had prenatal care. She may have placenta previa for all you know! You plan to change your protocols after this.
b) Excited for the birth, but fully aware of the fact that Juli has had a term loss, and may therefore have a dysfunctional labor. You haven’t had much time to work on this with Juli, but you have tricks up your sleeve, so expect things will go OK.
c) You’re very worried because she has signs of preeclampsia, and you know there are significant risks to both Juli and her baby. You plan to monitor her blood pressure carefully, and will transfer her at the first sign of it creeping up.
d) You’re slightly concerned about the fundal height being low, and worry there might be undiagnosed oligohydramnios. You’d planned to send her for an ultrasound as soon as possible to confirm or rule this out. You plan to continue care with Juli, but will have all resuscitation equipment prepped and ready, just in case the baby has trouble transitioning after birth.
A
184 . You’re showing your client a model of a placenta, umbilical cord, and membranes, to help explain the anatomy and physiology of pregnancy. What do you point out?
a) The outer membrane, called the chorion, and inner membrane, called the amnion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 vein and 2 arteries.
b) The outer membrane, called the amnion, and inner membrane, called the chorion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 vein and 2 arteries.
c) The outer membrane, called the amnion, and inner membrane, called the chorion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 artery and 2 veins.
d) The outer membrane, called the chorion, and inner membrane, called the amnion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 artery and 2 veins.
A
185 . You’ve read that open-ended questions are good in some situations. What is an example, and when is an appropriate time for its use?
a) Can you tell me about your homelife? Asked to help understand psycho-social health and emotional wellbeing.
b) Has your husband ever physically assaulted you? Asked to help identify abuse.
c) How much water did you drink yesterday? Asked to determine whether client is sufficiently hydrating.
d) Can you tell me about the dietary supplements you took this week? Asked to determine whether client started taking floradix.
A
186 . Jen complains that she isn’t sleeping well, and asks for recommendations of herbs or medications she might take to help with this. Which of these would not help with insomnia?
a) Yerba mate
b) Hops
c) Skullcap
d) Chamomile
A
187 . Urine dipsticks show positive for blood in all of these situations bar which?
a) Lower urinary tract trauma or infection has caused bleeding.
b) Conditions outside the urinary tract such as severe burns or injuries, ingestion of aspirin or hemolytic anemia.
c) Contamination from vaginal discharge containing blood.
d) Sometimes present in small quantities in healthy urine.
B
188 . Which of these is most likely to lead to a client telling you about their emotional state?
a) How have you been feeling this month?
b) Most mothers find this trimester is a time of great excitement and joy, but some women spend a lot of time worrying or even feeling sad about the fact their lives are about to change. How are you doing?
c) This month is often a hard one , and women sometimes feel like they do in transition: “I can’t do this”. Is that how you feel?
d) You look great! How do you feel?
A
189 . Which of these terms is not used to identify fetal lie?
a) Oblique
b) Transverse
c) Longitudinal
d) Breech
D
190 . Which of the following would not be part of appropriate emergency treatment for a uterine rupture?
a) Start an IV with lactated Ringer’s or normal saline.
b) Call 911 and request an ambulance. Call the hospital and tell them you suspect uterine rupture and tell them the client’s blood type.
c) Attempt to push the fetus back into the uterus.
d) Administer oxygen.
C
191 . Which of the following is not a good suggestion for management of a client with a history of a uterine prolapse following a previous pregnancy?
a) Cesarean delivery is indicated in some cases, but this may not prevent recurrence of uterine prolapse.
b) History of uterine prolapse is not a risk factor for subsequent prolapse, and so there should be no change in management antepartum. If cord traction is used in the third stage, this should be done using the normal guidelines.
c) Pelvic floor exercises can help prevent further prolapse.
d) Use of a vaginal pessary may successfully manage a uterine prolapse complicating the current pregnancy. Vaginal delivery is not necessarily contraindicated, even in this case, though careful monitoring for cervical infection is indicated.
B
192 . At her 20-week appointment, Lyzbeth complains of a mild stinging on urination. She produces a clean-catch urine sample, which is cloudy, smells bad, and which tests positive for leukocytes, nitrites and blood. You send a urine sample for culture, which tests positive for Escherichia coli. She does not have CVAT. Lyzbeth does not want to take antibiotics. Which of the following does not list alternative treatments Lyzbeth might consider?
a) Performing kegels while urinating, resisting the initial urge to urinate, nylon underwear, or ampicillin.
b) Uva ursi, burdock, corn silk, dandelion root, echinacea, horsetail, marshmallow root or stinging nettle.
c) Eliminating all dietary sugar, drinking adequate amounts of water, and urinating as soon as possible after feeling the urge.
d) Vitamin B supplementation, Vitamin C and cranberry juice or tablets.
A
193 . Which of the following is not a good recommendation for mitigating sciatica?
a) Yoga stretches such as alternating cat/cow and child’s pose can relieve the pain.
b) Try to sit down as much as possible, as this can reduce the inflammation of the sciatic nerve.
c) Heat or cold applied to the area can help ease the discomfort.
d) Chiropractic care may help realign pelvic joints, and a massage can help reduce inflammation (both should be with providers trained in care during pregnancy).
B
194 . Which is not a risk associated with a tubal pregnancy (that is not evacuated from the tube)?
a) Fetomaternal transfer (and hence RhD sensitization in subsequent pregnancies)
b) Maternal death
c) Ruptured fallopian tube
d) Congenital deformities in the neonate
D
195 . Which of the following is not a sign of a fetus in an occiput posterior position?
a) Fetal spine is difficult or impossible to palpate.
b) A concave shape is seen around the umbilicus.
c) Extreme symphysis pubis pain is felt during labor.
d) More fetal movement is palpated anteriorly, both left and right laterally.
C
196 . Which of the following would you not include in an informed consent document for your VBAC clients (in a state allowing VBACs)?
a) How management of pregnancy and labor differs from non-VBAC clients.
b) That all agreements are binding and clients cannot change their mind about TOLAC.
c) Risks involved with VBACs and ERCD, and their rates.
d) Rates of successful VBAC, nationally and in your practice.
B
197 . Maggie transfers to your care at 32 weeks with records from her previous provider, a midwife in another city. She had an ultrasound at 20 weeks and repeats at 24 and 28 weeks, which showed a constitutionally small baby, consistently measuring around 3 weeks smaller than average. All blood work has been normal throughout her pregnancy, and her previous midwife had no concerns about her. At 41.6 weeks, Maggie has shown no signs or symptoms of labor. BPPs have looked good, with a grade 2 placenta, normal AFL, and reassuring heart tones. What should you check?
a) Whether her date of conception is definitely accurate, or there’s a possibility she conceived later than thought.
b) Maggie should have a repeat ultrasound to diagnose or rule out IUGR.
c) Maggie should do daily kick counts to monitor the wellbeing of the fetus.
d) Maggie should have an ultrasounds with another provider to get a second opinion on the grade of the placenta.
A
198 . Which of the following lists accurate recommendations for nutrition and hydration during pregnancy?
a) Caloric needs increase as the pregnancy progresses, with very little change required in the first trimester but around 600 additional calories a day required by the third trimester. Protein requirements increase to around 80-100 g a day. A pregnant person should drink at least 8-10 cups of water each day, more if it’s hot or they’re exercising a lot.
b) Caloric needs are around 300 additional calories each day in first and second trimesters, but no additional calories needed in the third trimester due to the reduction in fetal exercise. Protein requirements increase to around 80-100 g a day. A pregnant person should drink at least 8-10 cups of water each day, more if it’s hot or they’re exercising a lot.
c) Caloric needs are around 300 calories each day throughout pregnancy. Protein requirements increase by around 30 to 50 g a day. A pregnant person should drink at least 64-80 oz of water each day, more if it’s hot or they’re exercising a lot.
d) Caloric needs do not change with pregnancy, though a significant increase in protein is required, with recommended intake almost doubling. Water intake should be at least 2 liters, and higher if it is hot or the pregnant person is exerting themselves a lot.
A
199 . Your student has been measuring fundal height accurately for several weeks now, so you’ve stopped checking her measurements every time, but you’re now reviewing a chart and spot what looks like an error. Where?
a) GA 12 weeks: 8cm
b) GA 16 weeks: 11 cm
c) GA 32 weeks: 34 cm
d) GA 40 weeks: 37 cm
A
200 . Which of the following non-allopathic methods would not be appropriate for attempting to turn a breech presentation to cephalic?
a) Belly binding.
b) Pulsatilla 30X and chiropractic adjustment.
c) Acupuncture or massage.
d) Moxibustion sticks.
A
201 . At 24 weeks, Lexi’s urine dipstick is all within normal limits, pulse is 80, respiration rate 22, temperature 97.4 and she’s gained 5 lb since her 20 weeks appointment. Fundal height is 28 cm, and you feel lots of small parts but no fetal spine. You cannot definitively identify the fetal head. When Lexi is lying semi-reclining, you find fetal heart tones near her umbilicus at 130-136 bpm, but when she rolls to her left side, you find heart tones lower down and on the right at 146-152 bpm. You decide to refer Lexi for an ultrasound. Why?
a) You suspect polyhydramnios.
b) You suspect supine hypotension.
c) You suspect the fetus is OP.
d) You suspect Lexi may be pregnant with multiples.
D
202 . Liv has kept her abdomen covered for all appointments until today. You see a thin, raised, white line running approximately parallel to and superior to her pubic bone. Which of these thoughts you might have is not true?
a) If Liv has had a cesarean section and lied about this, she is not safe for out of hospital care.
b) You can’t tell from looking at the scar when the incision was made, other than that it was not very recent.
c) The scar is horizontal, so, if it’s a cesarean scar, Liv had a low transverse cesarean section.
d) The scar could be from surgery besides uterine surgery.
C
203 . At 24 weeks, Mandy presents with signs and symptoms of candidiasis. She states that she doesn’t want to use allopathic medication because she worries it would harm the baby, but seems very reluctant to try non-allopathic remedies either. She tells you she can cope with the symptoms, so wants to just let it ‘run its course’. You tell her of the pros and cons of this, including risks for not treating it. Which of these was on your list for the latter part?
a) Placental abruption
b) Preterm birth
c) Pyelonephritis
d) UTI
B
204 . Which of these best describes an ectopic pregnancy?
a) A pregnancy implanted outside the endometrial cavity, i.e. in fallopian tubes, cervix, ovaries or abdominal cavity.
b) An embryo that is fertilized inside a fallopian tube.
c) An embryo that implants inside a fallopian tube.
d) An embryo that implants outside the uterus, i.e. in the fallopian tubes or in the abdominal cavity.
A
205 . Larissa is 34 weeks pregnant and her fetus is breech, confirmed by ultrasound. You explain various positions and exercises that she can try to help encourage a breech to turn. These include using a tilt board, forward leaning inversions, handstands in the pool, and knees and chest. What is the rationale for all of these exercises?
a) These exercises all create more room in the lower uterus. When getting back to upright, the fetus can then use this space and the pull of gravity to get into a better position.
b) These exercises cause the heavy fetal head to be pulled by gravity, moving the fetus into a cephalic position.
c) These exercises cause the anterior uterus to hang like a hammock, thereby encouraging the fetus to roll from posterior to anterior.
d) These exercises help move the fetus from transverse to oblique and then to cephalic.
A
206 . When putting together an informed consent document for external version (since the OB you refer to does not have one), what should you not include?
a) There is a risk of placental abruption, which is higher with a posterior placenta or placenta in the lower uterine segment.
b) There is a risk of cord compression or entanglement, so fetal heart tones should be checked throughout.
c) There is a risk that a small amount of fetal blood may enter the maternal bloodstream, and so Rh- clients should be offered RhoGAM.
d) There is a risk of premature rupture of membranes or preterm labor.
A
207 . Leah has been laboring for 10 hours and has refused vaginal exams until the point at which she says she’s ready to push. At this stage, you discover the fetal sacrum is the presenting part and birth is imminent. Which of these is not an action you should take?
a) Warm the room and your hands, and avoid contact with the baby until birth of the head is imminent, unless action is required.
b) If there is no chest crease when the baby has birthed to the umbilicus, the arms are trapped. Perform a maneuver such as Loveset to sweep arms down.
c) Ensure the head does not rotate to OP. When baby has delivered to neck, if the perineum is not bulging, the head is not well-flexed. Perform a maneuver such as Mauriceay-Smellie-Veit to secure flexion. Control the birth of the head if possible.
d) Encourage Leah to push hard and long from the first urge she has until the birth of the fetal head, when she should slow her pushing and attempt to ‘breathe the baby out’.
D
208 . Which of the following is not a way in which someone could aim to prevent a fetus from assuming an OP position?
a) Maintaining good posture (no slouching).
b) Chiropractic adjustments.
c) Taking a warm bath and gently massaging the baby over.
d) Sleeping on their left side.
C
209 . Mary, G2P1001, is a VBAC client who was given a cesarean for ‘failure to progress’. The obstetrician told her she’d been 4 cm for 3 hours because her baby was too big for her pelvis. Mary desperately wants a different outcome this time, but is very nervous about whether it will be successful. Which of these would you not tell her?
a) With a midwife, you’ll be doing lots to help get through that early labor stage, from how to face the pain to eating, hydrating and moving around, or resting if that’s the better option.
b) Although your pelvis hasn’t changed size or shape, there’s a chance this baby will be small enough to fit through. If you restrict calories from 36 weeks, you will improve your chances of a successful VBAC.
c) In early labor, it’s very common for progress to be slower. As long as you and your baby are handling labor well, we won’t rush you through this. Your body isn’t ‘broken’.
d) It would be good to join a group like the International Cesarean Awareness Network, as they are very supportive and you’ll hear a lot of success stories, helping you believe in yourself.
B
210 . Marge is 41w5d, and is now seeing you daily for prenatal appointments so that you can carefully monitor the health of the fetus. You’ve been palpating her abdomen and notice an apparent decrease in amniotic fluid volume. What should you do?
a) Oligohydramnios can lead to cord compression and fetal compromise. You should refer Marge for an ultrasound to confirm your suspicion, and transfer care to a hospital if it is correct.
b) Oligohydramnios increases the risk of prolapsed cord, especially if the fetus is not well-engaged at the time of ROM. You should arrange to attend immediately after ROM to check on fetal health.
c) Oligohydramnios is a sign that fetal urinary output has dropped, which indicates a problem with the kidneys. You should refer the neonate to a pediatrician within 24 hours of birth.
d) Oligohydramnios is physiological in post-date pregnancies, as fetal urinary output naturally drops as the fetus matures. You should continue expectant management, waiting for labor to start naturally.
A
211 . Kate’s urine specific gravity is 1.02. What does this mean?
a) Normal specific gravity values of urine are between 0.8 and 1.2. Since 1.02 is in the middle of that range, her hydration is perfect.
b) Normal values are between 1.015 and 1.05. 1.02 is on the lower side of this range, indicating that Kate is probably dehydrated.
c) Normal specific gravity values are 1 to 10. 1.02 is right at the lower boundary of normal, indicating that Kate is probably drinking a lot of water. Discuss hydration with her to ensure she’s not drinking too much.
d) The specific gravity of water is 1.0, so urine is always at least that high. 1.02 is on the higher side of normal, indicating that Kate is probably a little dehydrated (or has had diarrhea or vomiting).
D
212 . At her 16-week appointment, Liz complains of a slightly itchy vagina and a fishy smell after intercourse. On inspection, you see a grey, adherent discharge coating the vaginal walls, a pH of 4.5, and also note the fishy odor, and so you diagnose bacterial vaginosis. Liz does not want to take antibiotics, so you recommend various non-allopathic therapies, including echinacea tincture, bayberry bark infusion, probiotics and use of a tampon soaked in acidophilus culture. At 18 weeks, Liz contacts you to report no change in symptoms. She’s now tried every non-allopathic treatment she can find, but is reluctant to take antibiotics during pregnancy, and asks what the risks to the baby are of doing nothing. Which of these is not correct?
a) Chorioamnionitis
b) Spontaneous abortion
c) Pelvic inflammatory disease
d) Preterm birth
C
213 . Which of these do you not need to be able to inform clients about for local options for cesarean birth?
a) The cost
b) Which has more OBs that practice there
c) Which is the closest (at different times of day and with different traffic conditions)
d) Which have immediate emergency access and which have an on-call OB who might be away from the hospital
B
214 . Which of the following best describes what information an ultrasound ordered for a post-date client can give you?
a) AFI, fetal tone during the ultrasound, presence or absence of fetal breathing movements during the ultrasound, FHR (including variability and reactiveness) during the ultrasound, grade of the placenta, estimated fetal weight (large margins of error).
b) The ultrasound gives you exactly the same information as a biophysical profile, with the added benefit of estimated fetal measurements (e.g. the dimensions of the head), which can help predict problems such as CPD and shoulder dystocia.
c) Amniotic fluid volume; if this is low, there is an increased risk of fetal compromise. This value should be >5 cm and <16 cm.
d) Estimated fetal weight, amniotic fluid index, fetal gender, whether placenta is clear of the cervix, number of fetuses present, number of chambers of the heart, number of vessels in the cord.
A
215 . Specific gravity is more complicated than simply determining whether an individual is sufficiently well hydrated. Which of these statements about it is not true, though?
a) With impaired kidney function, specific gravity decreases, as the kidneys are less able to concentrate the urine.
b) Specific gravity normally increases as the amount of urine excreted increases.
c) Very pale urine with high specific gravity and glucose suggests diabetes insipidus.
d) With hypertension, there is usually normal urine volume, but increased specific gravity.
B
216 . At 34 weeks, Lana calls to tell you she has a headache that isn’t improved with acetaminophen, and blurry vision. On questioning, you discover that she’s producing very little urine, and she’s clearly very anxious. You ask to see her immediately, suspecting preeclampsia. Which of these do you not expect to see if that diagnosis is correct?
a) Fundal height that’s decreased or stayed unchanged since her previous appointment.
b) Blood pressure of 146/98.
c) Protein of over +1 on a dipstick.
d) Dizziness and/or syncope.
D
217 . By the end of pregnancy, which of these is incorrect for the total weight gain attributable?
a) Amniotic fluid: 2 lb
b) Uterine hypertrophy: 2 lb
c) Placenta: 3-4 lb
d) Increased blood volume: 3-4 lb
C
218 . Which of these is not a cause of a cystocele?
a) Chronic constipation
b) UTI
c) Vaginal childbirth
d) Violent coughing
B
219 . At her intake appointment, Luella tells you she’s had problems with hemorrhoids for years. At 24 weeks, she tells you they’re getting worse, and asks for advice on what she can do during pregnancy to help. Which is not a good suggestion?
a) Eat a diet high in animal products (meat, dairy, eggs)
b) Taking a red clover and nettle infusion
c) Using a compress of raw potato or witch hazel, and inserting Vitamin E into the anal canal if there’s inflammation
d) Use a stool when sitting on the toilet to reduce straining
A
220 . You’ve been monitoring Jaylin’s weight throughout pregnancy, and it’s been increasing an average of 2 to 3 lb every month. Today, she’s in for her 30-week appointment. What do you expect?
a) Her weight will probably have increased by at least 5 lb due to blood volume expansion. If it hasn’t, ask questions about her diet to try to determine whether she has reduced plasma expansion, which carries an increased risk of complications such as preeclampsia.
b) You probably won’t ask her to weigh herself today, as weight checks cause anxiety with no health benefit, and Jaylin has been doing very well so far.
c) Her weight will probably have increased by 4 or 5 lb, as the baby is growing very fast at this stage. If not, you expect to see a big jump at her next appointment.
d) Her weight will probably have increased by around 2 or 3 lb, since that’s her norm. If it’s gone up a little more, ask about her diet to see if there’s anything she can improve.
A
221 . At 38 weeks, Jerry confides in you that they’re worried they won’t be able to chestfeed because their chest isn’t big enough to produce enough milk for a baby. You ask to see Jerry’s chest and see no signs of insufficient glandular tissue/hypoplasia. Which of these might you have just seen?
a) A narrow gap between the areas of glandular tissue
b) Asymmetry between the two areas of glandular tissue, with one side much larger than the other
c) Areolas swollen or puffy
d) A ‘tube sock’ appearance, with no discernible growth or change during pregnancy
A
222 . Which of the following is not a physiologic body change during pregnancy?
a) Areolas, freckles, moles and the linea negra may all darken and enlarge during pregnancy.
b) Increase in the number of infections because the immune system is suppressed.
c) Relaxin loosens joints and ligaments (leading to ‘pregnancy waddle’, lordosis etc.)
d) Nails may become softer and more brittle, splitting more easily, but they also normally grow faster.
B
223 . Which is not a risk of cholestasis?
a) Fetal distress and stillbirth
b) Preterm birth
c) Postpartum hemorrhage, VKDB
d) Hypobilirubinemia in the fetus
D
224 . Kaiko is 10 weeks pregnant when she contacts you for advice on combatting the nausea and vomiting she’s experiencing. Which of these do you not tell her?
a) Try sucking on a hard candy
b) Drinking carbonated water may help
c) Apply acupressure to the medial malleolus (Sanyinjioa or SP6), 3 fingers’ width above the ankle bone.
d) Try eating dry crackers or toast before getting out of bed
C
225 . In a first trimester appointment with Meghan, you’re discussing exercise and ask about any separation of her abdominal muscles that she was told about after her last pregnancy. She says her doctor told her she had 3 fingers’ breadth of separation at one of her postpartum appointments. Which exercise is least likely to help prevent pathological diastasis recti with this pregnancy?
a) Sitting on a birth ball, hands on knees. Scooping in your abdomen and rolling back, easing off if you see a triangular shape forming on your belly.
b) Lifting weights and doing crunches in second and third trimesters.
c) “Hug your baby”: try lifting your belly button towards your spine so you’re hugging your baby using only your tummy muscles.
d) Engaging the pelvic floor and deepest layer of abdominal muscles (transverse abdominals) before moving. Roll to your side before sitting up.
B
226 . Lana’s blood pressure has been slowly rising for the last 3 visits, creeping up from 110/72 at her intake appointment at 10 weeks to 132/84 now, at 30 weeks. Which of these is not an appropriate suggestion for what she should do?
a) Drink 3 glasses of orange juice daily, and take bitter orange or guarana supplements.
b) Exercise for at least 30 minutes daily and work on meditation and stress reduction.
c) Ensure she’s eating enough protein, and eliminate caffeine from her diet. d) Add a calcium/magnesium/potassium supplement and drink hops or passionflower tea.
A
227 . At her 16-week appointment, Kayden asks you about drinking red raspberry leaf tea. Which of these do you not tell her?
a) Red raspberry leaf tea helps tone and tighten muscles of the uterus, and may help shorten the first stage of labor.
b) Kayden should not drink more than 1.5 quarts of the tea each day.
c) Red raspberry leaf tea may have laxative and diuretic properties.
d) The best time to start drinking red raspberry leaf tea is around 32 weeks gestation.
B
228 . Which does not list sign(s) or symptom(s) of intrahepatic cholestasis of pregnancy?
a) Black stools, pale urine.
b) Mild jaundice, serum bile acid 10 to 100 times the normal level.
c) Pruritus without lesions, beginning on the palms and soles of the feet, and spreading to the extremities and the trunk.
d) Anorexia, nausea and vomiting.
A
229 . Which statement about exercise during pregnancy is not accurate?
a) Since joints and ligaments are looser and hence more susceptible to injury during pregnancy, don’t aim for maximum resistance.
b) Kegels and squats are not recommended during pregnancy, as they tighten the pelvic floor, leading to potential dystocia.
c) Take care not to get dehydrated, and pay attention to your body and its limits.
d) Avoid stress on abdominal muscles and jerky motions, to reduce the risk of diastasis recti.
B
230 . Which of the following is not a potential management or treatment method for cholestasis?
a) Eating a diet high in fats, warm baths, tight-fitting clothes.
b) Ursodiol (prescription medication), cool or oatmeal baths.
c) Water-soluble Vitamin K (possibly only appropriate for clients with prolonged prothrombin time).
d) Elective cesarean or induction after 36 or 37 weeks.
A
231 . You’re putting together a handout on common discomforts of pregnancy, and reach ‘breast tenderness’. Which of these recommendations do you not include?
a) Do not wear bras with underwiring.
b) Tighten bra straps so that they dig into your shoulders, as this ensures your breasts are getting sufficient support.
c) Get fitted for a new, supportive bra whenever you feel your breasts have changed size (this may be more than once during pregnancy, and again postpartum).
d) Apply warmth to the breasts with heat packs or warm baths.
B
232 . Which of the following does not describe a presentation of placental abruption?
a) Subchorionic hematoma: an accumulation of blood between the uterine wall and the gestational membranes, including the placenta. The primary symptom is spotting or bleeding. Most result in uncomplicated pregnancies.
b) Partial: an edge of the placenta separates from the uterine wall. Symptoms are pain and bleeding. The fetus may survive if delivered immediately.
c) Complete: the entire placenta detaches from the uterine wall. Symptoms are massive bleeding, pain and fetal demise.
d) Hidden: center of placenta separates from uterine wall, with all edges remaining attached so that bleeding is contained behind the placenta. Severe uterine pain, fetal distress and a ‘woody’-feeling abdomen on palpation are the primary s/s. The fetus may survive if delivered immediately.
A
233 . Which of these factors does not increase the chance of a successful VBAC?
a) Prior vaginal birth
b) Eye movement desensitization and reprocessing (EMDR)
c) Cesarean section having been for non-repeat event (e.g. breech presentation)
d) Maternal BMI >30
D
234 . Maureen (G4P1202) is about 6 weeks away from her due date when she calls you to say she’s had a sore back all morning. You ask her where her back hurts and to describe the kind of pain, and she tells you it’s low down and kind of dull, but it gets worse in waves. Which of these actions would be most appropriate?
a) Tell Maureen this is nothing to worry about - it’s the baby dropping lower into her pelvis, getting ready for birth in a couple of weeks or so.
b) Recommend that Maureen wear a support band to help take the weight of her pregnant belly off her back.
c) Refer Maureen to your back-up physician because you suspect preterm labor.
d) Ask Maureen to drop a urine sample off at your office so you can send it for culture to find out if she has a UTI.
C
235 . Which of these would you not discuss with a client after a cesarean birth?
a) Breastfeeding and infant care, including how this differs from following a vaginal birth, such as how to position the baby to avoid putting weight on the incision.
b) Physical healing, including looking for signs of infection, monitoring pain level, blood loss, etc.
c) The possibility of a VBAC and what might make that more or less likely.
d) Emotional healing, ensuring that the client does not blame you for the fact that they did not have the vaginal birth they desired.
D
236 . You’ve confirmed premature rupture of membranes in Maddy at 38.4 weeks, who tested GBS negative at 36 weeks. You’re now reviewing with her what management will look like for her. Which of these do you not tell her?
a) Maddy should practice very good hygiene. She should wash hands before and after using the bathroom, should wipe backwards, should not have hand, mouth or genital contact with her vagina, and should not wear underwear or a pad if she can avoid it.
b) Maddy should drink plenty of water, eat high-quality, non-constipating food, and might want to consider non-allopathic labor stimulants such as B&B, Labor Enhancer or Start It Up.
c) You will be monitoring Maddy’s vital signs. If everything remains within normal limits, you can be confident that her baby has not developed an infection.
d) You will be listening to baby often, and Maddy should monitor her baby’s movement.
C
237 . You’re called in as assistant to a birth with a woman you don’t know, and arrive before the primary midwife. Contractions suddenly stop and the client’s pulse begins to rise. She’s looking pale and says she feels faint. When you listen to FHT, there’s been a significant drop in rate. What do you suspect?
a) Maternal anxiety
b) Uterine rupture
c) She’s experiencing a lull in contractions before second stage
d) Ketoacidosis
B
238 . A biophysical profile includes 5 components, each scored 0-2. Lower scores are associated with higher chances of neonatal morbidity and mortality. Which of these most accurately describes one of the components?
a) Fetal posture and tone: A score of 2 is given for at least one extension with return to flexion of fetal limbs, trunk or hand. A score of 1 is given for slow movement and only partial or no return to flexion. A score of 0 is given for no fetal movement.
b) Volume of amniotic fluid: A score of 2 is given for no amniotic fluid pockets. A score of 1 is given for the largest pocket of amniotic fluid being less than 2 cm in a vertical axis of AFI having pockets <2 cm in two right-angled planes. A score of 0 is given for an AFI of >5 cm and <16 cm.
c) Fetal body movement: A score of 2 is given for at least 1 episode of greater than 30 seconds of sustained fetal breathing movements/hiccups in 30 minutes. A score of 1 is given for breathing movements not sustained for 30 seconds. A score of 0 is given for an absence of fetal breathing movements.
d) Fetal size: A score of 2 is given for an estimated gestational age within +/- 5 days of the true gestational age. A score of 1 is given for an estimated gestational age within +/- 10 days of the true gestational age. A score of 0 is given for an estimated gestational age +/- 11 or more days from the true gestational age.
A
239 . Which is not true about the presence of nitrites on a urine dipstick?
a) Nitrites are produced by bacteria converting nitrates into nitrites, and hence are associated with the presence of bacteria.
b) Urine is more likely to show positive nitrites if it has not been retained in the bladder for more than 30 minutes.
c) The test is only accurately interpreted if there’s adequate nitrogen in the urine, which is reduced in those with diets low in protein.
d) If urine is positive for nitrites, a UTI should be confirmed with a culture, or assumed to be present and treated (with allopathic or non-allopathic treatments).
B
240 . Which of the following might help ease dyspareunia?
a) Position changes, such as side lying, hands and knees with partner behind, or standing.
b) Cranberry capsules or juice, increased water intake and ensuring you fully empty your bladder.
c) Meditation or a warm bath before bed, along with hops, skullcap or chamomile.
d) DHA has been shown to reduce the incidence of depression. If present, refer to a doctor and/or for counselling.
A
241 . Kehlani is 40 weeks, and is recapping normal fetal activity and fetal kick counts with you. Which of these questions of hers has ‘no’ as an answer?
a) Do hiccups count when I’m adding up kicks?
b) Should baby move more after I’ve drunk a glass of juice?
c) Is it OK if there are gaps of half an hour or so where I don’t feel baby move at all?
d) If baby kicks and then immediately hits me, does that still count as 1 movement for the kick count?
A
242 . Your friend works in a state where midwives routinely deliver twins. She tells you that she will happily do so if she knows there are two fetuses before birth, but she’ll call 911 if she discovers it during labor. Which is the best explanation for why?
a) She has no knowledge of the health of the second fetus, and probably does not have enough care providers present.
b) She may not have enough staff with relevant skills present, and she doesn’t know the position of the second fetus.
c) The second twin may interlock heads with the first, which has significant risk of fetal demise.
d) She is worried about the reaction she would get from her consulting physician if she delivered an unexpected second twin.
A
243 . Which of the following is not a probable contraindication for out of hospital VBAC?
a) Cesarean repaired with double-layer closure.
b) Previous inverted T cesarean section.
c) Previous vertical cesarean section.
d) Several prior cesarean sections.
A
244 . At her 34-week appointment, Melinda tells you that her husband’s work schedule is through, and he’ll be away from 38-42 weeks. She asks if you could help her go into labor at 37 weeks so that her husband will be home for the birth and the first few days postpartum. Which of these do you not tell her?
a) Compared to babies born during their 39th week, babies born between 38 and 39 weeks have up to double the risk of complications. Babies born between their 37th and 38th weeks have up to four times the risk.
b) 37 weeks is considered full term, so I could do a membrane sweep then. If your body isn’t ready to labor, you won’t start, so there aren’t really any risks associated with the procedure.
c) Babies born in their 37th or 38th week have higher risks, including for respiratory problems and sepsis (serious infection), than babies born in their 39th week.
d) Your due date could be off by a few days, so it’s possible we could be trying to deliver a 36-week baby. At that stage, baby would still be preterm, with significant risk (around 30%) of respiratory distress syndrome.
B
245 . Macaah calls at 34.2 weeks to report definite rupture of membranes. What is the most appropriate course of action?
a) Start a course of antibiotics to prevent fetal infection and practice expectant management.
b) Advise Macaah to monitor the amniotic fluid. If it develops a foul odor, they should be referred to a physician.
c) Advise impeccable hygiene, good hydration, and a healthful diet. If Macaah reports signs of infection, refer them to a physician.
d) Refer Macaah for steroids, antibiotics and continued care.
D
246 . Which of the following is not a symptom of preterm labor?
a) Constant menstrual-like cramps or low, dull backache.
b) Intermittent menstrual-like cramps or low, dull backache.
c) Vaginal dilation of 2 cm.
d) 5 or more contractions per hour.
C
247 . At her intake appointment, Mal asks you in what situations you would transport to hospital during labor or after the birth. Which of these is not one of the things you’d tell her?
a) You’d transport if her baby was struggling to transition after birth and needed more support than you could give.
b) You would only transport during labor if there was a true emergency.
c) You’d transport if the cord came out of the cervix before the baby, because then her baby would be at significant risk of not getting enough oxygen, because the cord would be squeezed by the baby’s head.
d) You’d transport if there was a postpartum hemorrhage that you couldn’t stop or if total blood loss was high even though you had stopped it.
B
248 . Which is the most accurate description of a non-stress test?
a) FHR is monitored continuously for approximately 20 minutes. If at least 2 accelerations of at least 15 bpm lasting at least 15 seconds are seen, results are reassuring.
b) Various components of fetal wellbeing are assessed, including posture, tone, movement and volume of amniotic fluid.
c) If the client is not already contracting, they are given IV Pitocin. Fetal heart rate and contractions are monitored to assess how well a fetus might cope with true labor.
d) Fetal heart rate is monitored for approximately 20-30 minutes. If any decelerations of at least 15 bpm lasting at least 15 seconds are seen, this is non-reassuring.
A
249 . Which of the following is not accurate regarding urinary pH?
a) Alkaline urine indicates a diet high in alkaline foods, such as nuts, vegetables and fruit. Bacteria grow more easily in alkaline urine.
b) Very alkaline urine can be a sign of poor nutrition or vomiting and/or diarrhea.
c) Alkaline urine is associated with UTIs, kidney stones or other kidney-related disorders.
d) Acidic urine normally indicates a diet high in protein, grains, fish, soda and/or sugary foods, and inhibits bacterial growth.
B
250 . At their 32-week appointment, Laron tells you their lower back is causing a lot of discomfort, and they’re not sure how to get through the rest of pregnancy, since it will surely get worse. You suspect the baby is in a posterior position, and palpate Laron’s abdomen; the fetus is actually LSA, so Laron does not have the baby’s head pushing on their sacrum. Laron has marked lordosis. Which suggestion is not appropriate for Laron?
a) You should wear a tight belly band to help take the weight of the baby off your lower back.
b) Regular exercise like yoga, swimming and pelvic tilts may help, and avoid standing still for too long.
c) When lifting, put your feet apart, one slightly in front, and stoop and use your legs to take the weight, not your back.
d) Heating pads and warm baths or an ice pack wrapped in a towel could both help.
A
251 . Karen’s 32-week urine dipstick with first morning urine shows 70+ leukocytes, negative for nitrites, urobilinogen, protein, blood, ketones, bilirubin and glucose, a specific gravity of 1.015 and a pH of 6.5. She reports higher than prepregnancy frequency, but has nothing else to report. What (if any) is the significance of the leukocytes, and in what way should Karen respond, if at all?
a) Leukocyte spill into urine is normal in pregnancy because of the increased blood volume and an increased burden on the kidneys.
b) The lack of nitrites or symptoms of a UTI and the fact that this appears not to have been a clean catch urine test all mean that evidence of a UTI is weak. Karen should produce a clean catch and you should test again before making recommendations for combating a UTI.
c) Karen is showing signs that she’s heading towards preeclampsia, and so you should recommend herbal treatments to help reduce that risk.
d) Since this was a clean catch, the leukocytes must have come from the urine, showing that Karen is fighting an infection in her urinary tract.
B
252 . At 30 weeks, Louris tells you she’s embarrassed to tell you this, but she has dark blue spots on her labia. She doesn’t want an exam, but describes them as looking like small purple grapes, and she says the area feels very swollen and ‘full’. You suspect vulvar varicosities, and, when you describe them to Louris, she agrees. Which of the following is not appropriate advice for her?
a) Don’t sit with your legs crossed, and use compression stockings.
b) Try to stimulate your circulation frequently by exercising.
c) Try not to stand for prolonged periods of time.
d) You could try taking 600 units of Vitamin E (not with other supplements, but with fatty food), nettle infusion (1-2 cups a day) or freeze dried nettle capsules, or collinsonia root tincture or tablets (up to 6 daily if needed).
A
253 . When calculating EDD, which of these methods is not correct?
a) Naegele’s rule: EDD = LMP - 3 months + 7 days or EDD = Conception - 3 months - 7 days
b) Using a gestation calculator wheel to determine 40 weeks from conception.
c) Wood’s method: Multips: EDD = LMP - 2 months 18 days + (cycle length - 28)
d) Wood’s method: Primips: EDD = LMP - 2 months 14 days + (cycle length - 28)
B
254 . Linda has refused the glucose tolerance test, but is now spilling significant glucose into her urine (including when precautions are taken to ensure this reading is as accurate as possible) and has ketonuria, too. She continues to refuse the glucose tolerance test, but appears very unmotivated to make any changes to her diet to mitigate the gestational diabetes you suspect. You decide to tell her some of the risks of uncontrolled gestational diabetes. Which of these is not a risk of GD?
a) The newborn has an increased risk of respiratory distress syndrome, hyperglycemia and hypercalcemia.
b) The pregnant person has a four-fold increase in risk of preeclampsia, ten-fold increase in the risk of polyhydramnios, and a high risk of postpartum hemorrhage.
c) Macrosomia increases the risk of prolonged labor and of shoulder dystocia.
d) Fetus responds to increased blood glucose levels by greatly increasing the production of insulin, leading to macrosomia.
A
255 . At her intake appointment at 11 weeks, Keona tells you she’s worried because she’s been feeling exhausted, even though the baby is tiny still. Which of these would you not say to her?
a) Fatigue can be a sign of anemia, but the blood test we’re doing will tell us if that’s the case for you, and it’s an easy thing to solve if it is.
b) Eating a healthy diet, and alternating resting with exercise can all help mitigate fatigue.
c) Fatigue is normal in the first trimester and usually disappears by the second trimester, so you’re nearing the light at the end of the tunnel!
d) Just wait until you have a 2-year-old! You’ve no idea!
D
256 . Marie is 8 weeks pregnant when she calls you at 2am to report severe abdominal pain, vomiting, a racing heart, high temperature, and she feels faint. She also describes a blue area that recently appeared below her belly button and says her neck hurts when she breathes in. What do you do?
a) Tell Marie you think she has preeclampsia and she should go to the nearest labor and delivery immediately.
b) Tell Marie she’s having a panic attack, and should call her PCP tomorrow DURING BUSINESS HOURS!
c) Tell Marie to go straight to the ER for a suspected rupture of an ectopic pregnancy, and tell her you’ll meet her there if possible.
d) Tell Marie she probably has a gastrointestinal upset. She should keep drinking small sips regularly to maintain hydration until she recovers.
C
257 . At 37 weeks, you palpate Lela’s abdomen and identify that the fetus is ROT, with no cephalic prominence felt, but with easily palpable spine and small parts. Fetal heart rate is 142-146 bpm, and fundal height is 35 cm. What is your primary concern from this exam?
a) The fetus should be on Lela’s left, as this reduces the risk of a posterior labor and birth.
b) There are signs of oligohydramnios, which is associated with an increase in fetal mortality due to underlying conditions.
c) The fundal height is low, indicating IUGR, which is associated with polycythemia, hypoglycemia and hypothermia.
d) The fetal head is not well-flexed, which could cause labor dystocia.
B
258 . At her 20-week appointment, Lyzbeth complains of a mild stinging on urination. She produces a clean-catch urine sample, which is cloudy, smells bad, and which tests positive for leukocytes, nitrites and blood. You send a urine sample for culture, which tests positive for Escherichia coli. She does not have CVAT. Lyzbeth does not want to take antibiotics, but, when following up by phone at 21 weeks, you discover that she’s not following recommendations you gave her on non-allopathic treatments, and she now has lower back pain and thinks she may have a fever. In urging her to treat the infection, you want to share some risks of UTIs with her. Which of these is not a risk associated with UTIs and pyelonephritis?
a) Prolonged labor, shoulder dystocia, and postpartum hemorrhage.
b) Fetal death, low birth weight, low APGARS, or cerebral palsy.
c) Maternal hypertension or preeclampsia, preterm labor, or PPROM.
d) Anemia, septicemia, shock, and adult respiratory distress syndrome.
A
259 . Katya is 34 weeks pregnant when she tells you she’s very itchy on her belly, breasts and back. Which of these is not a good recommendation for helping ease this?
a) Take a liver tincture with dandelion root and yellow dock.
b) Eat foods high in choline, such as wheat germ and brewer’s yeast.
c) An oatmeal bath can provide great comfort.
d) Eat liver-healthy foods such as raisins, salty foods and foods with a high saturated fat content.
D
260 . Maddy calls you at 38.4 weeks to tell you she “woke up in a puddle” and isn’t sure if she had urinary incontinence or if her membranes ruptured. Which of these statements about identification of rupture of membranes is not accurate?
a) The fern test may produce false positives if there is contamination with blood, semen or cervical mucous.
b) An abdominal ultrasound can confirm low levels of amniotic fluid, but cannot reliably confirm rupture of membranes.
c) A blood test for fetal fibronectin (fFN) to diagnose PROM has both high sensitivity and specificity.
d) Nitrazine paper may give a false positive with presence of a vaginal infection (such as BV), of semen, or of soap.
C
261 . Which two factors most accurately predict the probability of a successful VBAC?
a) Whether or the client has had a prior vaginal birth, and the thickness of the uterine scar.
b) Whether or the client has had a prior vaginal birth, and whether or not labor is spontaneous.
c) What the interdelivery interval is, and the thickness of the uterine scar.
d) What the interdelivery interval is, and whether or not labor is spontaneous.
B
262 . Marge (G5P4004) joins your practice at 16 weeks. When you’re calculating her due date, she tells you that her menstrual cycles are regular at 28 days, that she only had intercourse on cycle days 13 and 20, and got a very faint positive pregnancy test on day 24. Her previous pregnancies had somewhat similar scenarios, and GA at the times of birth were 41w6d, 41w5d, 42w3d, 42w1d. You live in a state where midwives can only legally deliver babies until 42w0d. What should you do?
a) Counsel Marge that, whilst you’re happy to care for her during pregnancy, there’s a significant chance that her pregnancy will go to post term, at which stage you’d need to transfer her care. You could still attend the birth, but in the role of a doula, not a midwife.
b) You expect that Marge will go to post term, but safely so, as all her other pregnancies resulted in healthy babies. Since your state’s laws are not flexible on this, you should record her GA as 2 weeks behind its true value throughout pregnancy.
c) Marge is likely to go to post term if there is no significant change to this pregnancy, and she’s desperate to have an out of hospital birth with a midwife, so you suggest to her the idea of smoking during pregnancy.
d) Since it’s likely that Marge will go post term without assistance, you recommend starting herbs, castor oil, a membrane sweep and AROM at 40w.
A
263 . At her prenatal appointment at 11am one morning, Kira tells you she struggled to leave a urine sample because she’s not drunk anything yet today. When you look at what she has produced, it’s very pale. Which of these could have caused this observation?
a) Impaired kidney function. Specific gravity values fall as kidneys are less able to concentrate the urine.
b) Kira probably has a UTI, which is causing the urine to look more dilute than it really is.
c) Urine is normally clear when very concentrated, and dark when dilute, and so this is normal.
d) The pH is probably very high or very low, as either extreme causes dilution of the urine in the bladder.
A
264 . Which of these is not a correct recommended range for total weight gain during pregnancy for different BMI categories?
a) Normal weight: 25-35 lb
b) Underweight: 20-30 lb
c) Obese: 11-20 lb
d) Overweight: 15-25 lb
B
265 . Which of the following is not a synonym of the others?
a) Rectocele
b) Bladder prolapse
c) Anterior prolapse
d) Cystocele
A
266 . Lisa complains of listlessness (including restless legs), a brain fog, tiredness, fever, dizziness, a headache, sore tongue, palpitations, shortness of breath and an urge to eat coal. You suspect iron deficient anemia, but which complaint Lisa listed is not a symptom of iron deficient anemia?
a) Brain fog
b) Palpitations
c) Sore tongue
d) Fever
D
267 . Which of these statements about cesarean birth is not true?
a) Dissolvable sutures will be used, and there should then be careful monitoring of the healing of the incision.
b) If time permits, it’s important to inform clients transferring for a cesarean of what they will experience regarding bright lights, the large number of people present, lots of sounds, monitors, etc.
c) There is normally a feeling of “tugging” and of pressure, even with anesthesia working correctly.
d) Cesarean sections should only be considered for emergency situations, such as placental abruption or cord prolapse, as the risks involved in major abdominal surgery are significant.
D
268 . The following are all risk factors for which complication of pregnancy? Pelvic inflammatory disease, IUD in situ, history of tubal ligation, in vitro fertilization.
a) Stillbirth
b) Multiple pregnancy
c) Ectopic pregnancy
d) Molar pregnancy
C
269 . Leticia, who had an OB care for her until 23 weeks, joined your practice at 28 weeks. Since then, she has had the following fundal heights: 28 weeks: 25 cm, 30 weeks: 26 cm, 32 weeks: 27 cm. On palpation, amniotic fluid levels appear normal and the fetus feels small for gestational age, though possibly with a normally sized head. The head is still high. You referred Leticia for an ultrasound when she first joined your practice, and refer for a second one now. Which is the best explanation for why?
a) You suspect that the fetus is constitutionally small for gestational age, but need to monitor placental health to ensure the fetus remains safe for out of hospital birth.
b) You suspect that the fetus has intrauterine growth restriction. To differentiate this from a fetus that is small for gestational age, serial ultrasounds are required. If present, there are significant risks to the fetus, and referral to an obstetrician is appropriate.
c) You suspect that the fetus has intrauterine growth restriction. To differentiate this from a fetus that is small for gestational age, the IUGR fetus will measure below the 5th percentile for weight for that gestational age. If present, there are significant risks to the fetus, and referral to an obstetrician is appropriate.
d) You suspect that the fetus is constitutionally small for gestational age, but need to rule out congenital anomalies to ensure it remains safe for out of hospital birth.
B
270 . Leilah calls you at 29 weeks to tell you she’s been feeling cramping and pulling in her uterus, and she’s worried it’s pre-term labor. On further questioning, you discover that the sensations are just on the sides of her belly, and does sometimes happen after sudden movement. Which of these is the most accurate explanation of what’s going on and a good suggestion for what Leilah should do?
a) Leilah seems to be feeling the round ligaments (which help support the uterus) being stretched. One suggestion for helping relieve the discomfort is pelvic lift exercises.
b) Leilah seems to be feeling the tendons (which help support the uterus) being stretched. One suggestion for helping relieve the pain is sleeping with good support from pillows.
c) Leilah seems to be feeling the round ligaments (which contract to help open the cervix) being stretched. One suggestion for helping relieve the discomfort is avoiding sudden movements.
d) Leilah seems to be feeling the tendons (which contract to help open the cervix) being stretched. One suggestion for helping relieve the pain is wearing a fitted maternity belt to help decrease the pressure on the tendons.
A
