NARM Practice Exam 600 Questions - (271-480) Labor, birth and immediate postpartum

Question 1

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

Answer 1

D

Question 2

272 . You arrive at Noelle’s house 20 minutes after she called you, and it’s clear she’s in second stage already. You go to put on gloves and see a sacrum rumping and, shortly afterwards, the fetus rotating and the legs releasing. As you reach her, you see that there is no cleavage - it is pulled tight on both sides. What (if anything) do you do?
a) Grip the shoulders with both hands. Disimpact and rotate 90 degrees (from ST to SA) and release the posterior arm. Disimpact and rotate 90 degrees back to ST and release the other arm, if indicated.
b) Insert posterior hand so the middle finger is on the fetal occiput, and anterior hand so the first finger is in the fetal mouth. The added benefit of this position is that you can easily feel fetal heartrate. If the fetus is sucking on the finger, this is another reassurance. Push gently on the occiput and pull the chin down. Perform a shoulder press if indicated.
c) Place hands on fetal front and back, prayer pose. Disimpact the fetal arm and rotate towards SP. Sweep (what had been) the anterior arm out and then elevate and rotate 180 degrees to SA. Sweep the other arm, if indicated.
d) Hands off the breech! This is normal, and so you wait to catch the baby as the head releases spontaneously.

Answer 2

C

Question 3

273 . After suturing a second-degree tear and completing the newborn screen, your client is breastfeeding her neonate when she tells you she feels pressure in her vagina, and it really hurts. You perform an exam of the area, and see an area of tissue that has a blueish color to it just above the apex of her tear. When you gently palpate the area, you feel a fluctuant swelling. What do you suspect, and what course of action should you take?
a) Rectocele. Reassure the client that, with correct exercises, this is likely to significantly improve. In the interim, if she struggles to have a bowel movement, she should try applying pressure to the perineum or on the posterior vaginal wall.
b) A vaginal hematoma. If it is small, it may be spontaneously absorbed, but if it continues to enlarge, transfer of care to a physician is appropriate.
c) Thrombophlebitis in a vaginal vein. Emergency transport is required to prevent pulmonary embolism.
d) Broad ligament hematoma. Apply direct pressure to the area to prevent further expansion, and consult with a physician.

Answer 3

B

Question 4

274 . Which of these is not a complication associated with cephalohematoma?
a) Erb’s palsy
b) Defective blood clotting
c) Intracranial bleeding
d) Jaundice

Answer 4

A

Question 5

275 . Which of the following is a correct definition regarding FHR?
a) Prolonged deceleration: an episodic drop in FHR of more than 15 bpm below baseline, which lasts between 2 minutes and 10 minutes.
b) Late deceleration: a gradual decrease in FHR over at least 30 seconds, reaching their nadir after the contraction peaks, and abruptly returning to baseline within 5 seconds of the contraction ending.
c) Episodic change: acceleration or deceleration patterns that occur in relation to uterine contractions.
d) Early deceleration: a deceleration that begins shortly before a contractions starts, abruptly decreases over 15 seconds or less, and returns to baseline as the contraction tapers off.

Answer 5

A

Question 6

276 . You saw Nika (G1) 3 days ago, at 39.6 weeks, and estimated fetal weight at around 9 lb. Today, she calls you to her labor and you arrive shortly before second stage. She delivers a baby that you estimate to be around 6 lb, with APGARS of 9 and 10. You keep an eye open for lengthening of the cord or a gush of blood and see none. Nika then reports strong contractions, and you see the perineum bulge, but still see to lengthening of the cord. What do you suspect?
a) Placenta is delivering
b) Uterine inversion
c) Placenta accreta
d) Surprise twin

Answer 6

D

Question 7

277 . Nani gave birth to a healthy GA 41.0-week baby two hours ago. Which of the following is not an important thing she should have done by now?
a) Spent time holding her baby, breastfeeding if she is doing so.
b) Continued drinking, and had something nourishing to eat.
c) Called around her family to tell them of the birth.
d) Voided postpartum.

Answer 7

C

Question 8

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

Answer 8

B

Question 9

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

Answer 9

A

Question 10

280 . Which of the following scenarios with a multiple pregnancy/birth does not increase risk (to either/both parties)?
a) First twin’s placenta delivers before birth of second twin.
b) Both twins are longitudinal, with first twin breech and second cephalic.
c) Twins are monochorionic.
d) The twins are dizygotic.

Answer 10

D

Question 11

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

Answer 11

D

Question 12

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

Answer 12

C

Question 13

283 . The following are all signs of what condition? Inefficient transfer of milk, clicking noises when nursing, thick or short glossal frenulum.
a) Lip tie
b) Tongue tie
c) Macroglossia
d) Cleft lip

Answer 13

B

Question 14

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

Answer 14

A

Question 15

285 . In which of these situations would use of a birth pool (continue to) be appropriate?
a) The client needs to urinate
b) Fetal tachycardia or a rise in maternal temperature of 1 degree above baseline.
c) Rupture of membranes occurring 31 hours prior to use.
d) The client needs a bowel movement

Answer 15

A

Question 16

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

Answer 16

B

Question 17

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

Answer 17

A

Question 18

288 . Which of the following descriptions correctly identify features of (1) recurrent variable decelerations not associated with fetal acidemia and (2) variable decelerations that are associated with fetal acidemia and require urgent action?
a) (1) Return to baseline is gradual (2) Return to baseline is abrupt
b) (1) Duration >60 seconds (2) Duration <45 seconds
c) (1) Shouldering is seen (2) Overshooting is seen
d) (1) Baseline rate unchanged (2) Baseline rate is rising

Answer 18

C

Question 19

289 . Which of the following terms is paired with a correct description?
a) Infarcts: small, gritty white areas scattered all over the maternal surface of the placenta.
b) Lobulated placenta: one or more smaller accessory lobes of placenta are developed in the membranes, a variable distance away from the main placental mass, attached to the main placenta by fetal vessels.
c) Battledoor placenta: the blood vessels of the umbilical cord separate and leave the cord prior to insertion, and are thus not protected by Wharton’s jelly. They course between the chorion and amnion for a variable distance before entering the placenta surrounded only by amnion.
d) Placenta circumvallate: membranes arise a short distance inward of the placental edge, and fold back on themselves, creating a grey/white ring around the margin of the placenta. Fetal vessels stop here.

Answer 19

D

Question 20

290 . Which of the following should not be done between birth and expulsion of the placenta?
a) Check vital signs.
b) Encourage nursing.
c) Massage of uterus to stimulate contractions.
d) Ensure the client has an empty bladder.

Answer 20

C

Question 21

291 . Nafula (G1) is experiencing a shoulder dystocia of her baby. You’ve rapidly moved from one step to another, repositioning Nafula and attempting several maneuvers. None have been successful, and you now decide you must fracture the fetal clavicle. Which do you aim to avoid doing, unless this is the only way to resolve the dystocia?
a) Slide middle finger behind the anterior clavicle (from cephalic direction) and press it outwards.
b) Use two thumbs to press down posteriorly on the center of the anterior clavicle.
c) Hook middle finger below and then behind the anterior clavicle and press it outwards.
d) Hook both thumbs under the middle of the clavicle and pull towards the fetal head.

Answer 21

B

Question 22

292 . Which of the following is a normal finding for head circumference at the newborn exam?
a) 32-37 cm (12.5-14.5”) and approximately 2cm (0.75”) larger than the chest.
b) 32-37 cm (12.5-14.5”) and approximately 2cm (0.75”) smaller than the chest.
c) 29-34 cm (11.5-13.5”) and approximately 2cm (0.75”) smaller than the chest.
d) 35-40 cm (13.75-15.75”) and approximately 2cm (0.75”) larger than the chest.

Answer 22

A

Question 23

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

Answer 23

A

Question 24

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

Answer 24

A

Question 25

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

Answer 25

B

Question 26

296 . Which of the following observations of genitals in a female baby born at 41.2 weeks would lead you to think there might be a discrepancy in dates?
a) Prominent labia majora
b) White vaginal discharge with a small amount of blood
c) A hymenal tag
d) Prominent labia minora and clitoris

Answer 26

D

Question 27

297 . The following are all side effects of which medication commonly used in the treatment of postpartum hemorrhage? diarrhea, shivering, pyrexia, nausea, vomiting, abdominal pain.
a) Methergine
b) RhoGAM
c) Pitocin
d) Misoprostol

Answer 27

D

Question 28

298 . Which of the following is not an accurate description of the degree of a perineal laceration?
a) Fourth degree: Laceration involves those of a third-degree tear, plus the anterior rectal wall.
b) Second degree: Laceration involves those of a first-degree tear, plus perineal muscles.
c) First-degree: Laceration involves the vaginal mucosa, posterior fourchette, and perineal skin.
d) Third degree: Laceration involves those of a second-degree tear, plus tears to the periurethral area.

Answer 28

D

Question 29

299 . When auscultating the neonatal heart of a quiet and still baby an hour after birth, which of the following is a normal finding?
a) Irregular rhythm
b) Harsh, blowing and pansystolic, or harsh, continuous and thunder-like sound.
c) S1 (“lub”) and S2 (“dub”) sounds, but no S3 (“ventricular gallop”) or S4 (“atrial gallop”) sounds.
d) Bounding pulse

Answer 29

C

Question 30

300 . You’re examining the placenta and membranes shortly after they’ve been delivered, and note blood vessels that extend from the placenta into the membranes, and that then end at the edge of the membranes. What significance does this have, if any?
a) This indicates that the pregnancy began as a multiple pregnancy, but the second twin was lost. The risks of this are antepartum, and so there is no risk at this stage.
b) This indicates that a succenturiate lobe may be missing. There is risk of hemorrhage and infection if it is not delivered/removed from the uterus.
c) This indicates that a second lobe of the placenta may be missing. There is risk of hemorrhage and infection if it is not delivered/removed from the uterus.
d) This is called a velamentous cord insertion. The risks of this are intrapartum ones, and so there is no risk at this stage.

Answer 30

B

Question 31

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

Answer 31

A

Question 32

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

Answer 32

A

Question 33

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

Answer 33

D

Question 34

304 . Which of the following descriptions of a type of birth mark is incorrect?
a) Congenital melanocytic nevi (moles): most are brown, but may be shades of pink, red or black. Sometime have raised areas or hair. Normally benign, but if more than 1 is present, the neonate should be evaluated by a physician.
b) Nevus flammeus/Port wine stain: flat pink or red birthmark. Benign, but grows darker and thicker over time.
c) Café-au-lait: two sets of DNA are present in the same person, affecting the color of the skin. The changes may be subtle or large, and birthmarks may form lines or swirls. May become more apparent later in life, particularly with sun exposure.
d) Nevus simplex (‘salmon patch’/’angel kiss’/’stork bite’): flat pink or red birthmarks located on eyelids, forehead, back of the neck, top of the head, under the nose, and on the lower back. Exaggerated with exertion. Benign and fade over early childhood.

Answer 34

C

Question 35

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

Answer 35

B

Question 36

306 . What colors and timing should you see in newborn stools in the first week?
a) First 24-48 hours: black/dark green. Days 2-3: beginning of transitional stools of thinner browner/yellower green. By day 6: full transition to milk stools, normally mustard colored (sometimes with ‘seeds’) for breastfed babies and tan-brown for formula-fed babies.
b) First 48-72 hours: black/dark green. Days 3-5: beginning of transitional stools of thinner browner/yellower green. By day 10: full transition to milk stools, normally mustard colored (sometimes with ‘seeds’) for breastfed babies and tan-brown for formula-fed babies.
c) First 24-48 hours: black/dark green. Days 2-3: beginning of transitional stools of thinner browner/yellower green. By day 6: full transition to milk stools, normally mustard colored (sometimes with ‘seeds’) for formula-fed babies and tan-brown for breastfed babies.
d) First 48-72 hours: black/dark green. Days 3-5: beginning of transitional stools of thinner browner/yellower green. By day 10: full transition to milk stools, normally mustard colored (sometimes with ‘seeds’) for formula-fed babies and tan-brown for breastfed babies.

Answer 36

A

Question 37

307 . For an LOA fetus that has engaged (the biparietal diameter of the head has passed through the pelvic inlet), which of these is not a correctly described cardinal movement for normal birth?
a) 4. Lateral flexion or expulsion causes the fetus’s shoulders and body to be born. Normally, the posterior shoulder impinges under the symphysis pubis and the anterior shoulder then distends the perineum and is born by lateral flexion.
b) 1. Extension of the head causes the head to be born
c) 2. Restitution occurs when the head turns 45 degrees so that it is once again at a right angle to the shoulders
d) 3. External rotation occurs when the shoulders rotate 45 degrees, bringing the bisacromial diameter into alignment with the anteroposterior diameter of the pelvic outlet

Answer 37

A

Question 38

308 . Which of the following is true about uterine contractions?
a) Tachysystole is defined as at least 5 contractions in 10 minutes.
b) Frequency of contractions is calculated by measuring the length of time for which the uterus is relaxed.
c) If contractions slow at any time during labor, this indicates a complication has arisen. Check vital signs, FHTs, look for uterine rupture, malpositioning or clinical exhaustion.
d) Palpation of the uterus during a contraction informs you of how well a client is dilating.

Answer 38

A

Question 39

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

Answer 39

C

Question 40

310 . Nix recently birthed their baby and you’re now inspecting their perineum and birth canal. They have what appears to be a second-degree tear, and you see active bright red bleeding, with the blood coming in pulses. Which of the following are you not going to do?
a) Clamp bleeding vessel(s), if you can identify any.
b) Suture a third- or fourth-degree tear.
c) Apply direct pressure to the tear.
d) Suture a first- or second-degree tear, or a labial tear.

Answer 40

B

Question 41

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

Answer 41

A

Question 42

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

Answer 42

C

Question 43

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

Answer 43

B

Question 44

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

Answer 44

A

Question 45

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

Answer 45

A

Question 46

316 . Which of the following is likely to make bleeding worse if given to a client experiencing PPH?
a) Shepherd’s Purse
b) Asking the client to focus on stopping her bleeding
c) Caulophyllum
d) Angelica Sinensis (Dong quai)

Answer 46

D

Question 47

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

Answer 47

C

Question 48

318 . When examining a newborn’s spine, you notice a sacral dimple. Which of the following statements is not accurate?
a) If there is a hair growing in the dimple, refer to a pediatrician as soon as possible.
b) You should probe the pit to determine if it is closed. If it is not, refer to a pediatrician as soon as possible.
c) If there is moisture around a dry dimple, refer to a pediatrician as soon as possible.
d) If the bottom of the pit is not visible, refer to pediatrician as soon as possible.

Answer 48

B

Question 49

319 . The baby your client just delivered has a cleft lip that was not diagnosed prenatally. In which of these situations would you not need to initiate immediate transfer?
a) Signs of respiratory distress with nursing.
b) Evidence of other undiagnosed anomalies.
c) Neonate appears unable to transfer milk.
d) Neonatal latch draws in more areola caudally than cranially.

Answer 49

D

Question 50

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

Answer 50

C

Question 51

321 . Which of the following conditions does not involve congenital limb length discrepancy?
a) Focal femoral deficiency
b) Achondroplasia
c) Hemihypertrophy
d) Fibular hemimelia

Answer 51

B

Question 52

322 . Which of the following, regarding a neonate’s pupils, is a normal finding?
a) Pupil of one eye constricts with illumination of the opposite eye.
b) One or both pupils not round.
c) Pupils are of unequal sizes.
d) Pupil does not constrict under direct illumination.

Answer 52

A

Question 53

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

Answer 53

A

Question 54

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

Answer 54

A

Question 55

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

Answer 55

D

Question 56

326 . Which of these ranges is not correct for a newborn?
a) Rectal temperature: 98.1 to 100.2 F (36.7-37.9 C). Note that the thermometer could perforate the rectum and/or cause a vagal response.
b) Weight: 5lb 5oz to 10lb 2oz
c) Axillary temperature: 97.7 to 99.8 F (36.5 to 37.7 C)
d) Length: 18” to 22” (45.5cm to 60cm)

Answer 56

C

Question 57

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

Answer 57

B

Question 58

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

Answer 58

A

Question 59

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

Answer 59

D

Question 60

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

Answer 60

D

Question 61

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

Answer 61

C

Question 62

332 . When performing a newborn exam, you note that the nostrils widen on every inhalation. What does this signify?
a) The neonate is upset.
b) Respiratory distress.
c) There is no clinical significance.
d) The nostrils are fully obstructed.

Answer 62

B

Question 63

333 . Which of the following is most concerning?
a) Central cyanosis that worsens with crying.
b) Circumoral cyanosis that appears during crying.
c) Acrocyanosis at the time of the 5-minute APGAR.
d) Peripheral cyanosis in a neonate wrapped in a damp blanket.

Answer 63

A

Question 64

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

Answer 64

D

Question 65

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

Answer 65

C

Question 66

336 . When performing a newborn screen, you notice that both hands have one crease running across them, not the normal two. Which of the following is not an accurate statement?
a) This is associated with several syndromes, including Down Syndrome, fetal alcohol syndrome, and congenital rubella syndrome.
b) You should tell the parents of the presence of ‘simian creases’.
c) You should record ‘bilateral single transverse palmar creases’ in the chart.
d) This is a normal variation seen in approximately 5% of the population.

Answer 66

B

Question 67

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

Answer 67

A

Question 68

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

Answer 68

D

Question 69

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

Answer 69

C

Question 70

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

Answer 70

B

Question 71

341 . The neonate you’re assessing has a barrel-shaped chest, cyanosis, respiratory distress and uneven breath sounds with diffuse rales and ronchi on auscultation. What do you suspect, and what action do you take?
a) Transient tachypnea of the newborn. Give blow-by oxygen until breathing improves.
b) Fluid in the lungs. Use CPAP until it has been absorbed and breath sounds are normal.
c) Immature central nervous system. Check gestational age with New Ballard Scale, and transport if <36 weeks.
d) Meconium aspiration syndrome. Initiate immediate transport.

Answer 71

D

Question 72

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

Answer 72

C

Question 73

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

Answer 73

B

Question 74

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

Answer 74

A

Question 75

345 . Which of the following best describes a ‘ripe’ cervix?
a) Soft, effaced, dilated, anterior.
b) Soft, effaced, dilated, posterior.
c) Medium, effaced, dilated, midposition.
d) Soft, long, posterior, engorged.

Answer 75

A

Question 76

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

Answer 76

D

Question 77

347 . When assessing a newborn’s breathing, which finding would be normal?
a) Use of accessory muscles
b) Grunting
c) Stridor (high-pitched musical breathing sound)
d) Abdomen rises and falls with breathing

Answer 77

D

Question 78

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

Answer 78

C

Question 78

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

Answer 78

B

Question 79

350 . Which is not a risk of manually removing the placenta?
a) Placenta accreta.
b) Uterine inversion.
c) Torrential hemorrhage.
d) Uterine infection.

Answer 79

A

Question 80

351 . Nadina has had prodromal labor for 3 nights and has now been in active labor for 9 hours, with three episodes of emesis. You’re aware of the risk of maternal exhaustion, and are working to manage this. Which of the following is not appropriate management?
a) Monitor maternal and fetal vital signs, including testing for ketonuria.
b) Recommend that Nadina have nil by mouth because there is an increased risk of emergency cesarean section.
c) Consult if any signs are concerning, and transport if Nadina’s vital signs are above normal ranges or FHT are non-reassuring.
d) Recommend rest, a warm bath, and removal of distractions.

Answer 80

B

Question 81

352 . You’re doing a newborn exam and are looking at the tongue. Which of these findings is not paired correctly with a possible cause?
a) Macroglossia: hypothyroidism.
b) Tongue heart-shaped: ankyloglossia.
c) Deviation from midline: Cranial nerve damage.
d) Tongue-thrust with depression of the tongue: Metabolic disorder.

Answer 81

D

Question 82

353 . Nachni (G1) told you after her last contraction that she thought she felt the urge to push, but is now pushing through this contraction and seems confused about how to do it. Her vital signs are all within normal limits, FHT are reassuring, and there are no known complications, including malpresentations. Which of the following is your best course of action?
a) Suggest that Nachni sit on a birthing stool and then talk her through pushing with Valsalva (breath holding) technique.
b) Tell Nachni that an ideal position is squatting, and have her use a birth sling to achieve this. Show her how to tuck her chin in to her chest and curl around her belly as she pushes.
c) Suggest that Nachni breathe through a couple of contractions and wait until the urge to push is stronger, and then listen to her body’s instincts on position and technique.
d) Tell Nachni to get into hands and knees and push only once the contraction reaches its peak, resting between contractions.

Answer 82

C

Question 83

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

Answer 83

B

Question 84

355 . Which of these statements correctly differentiates between a feature of a caput succedaneum and a cephalohematoma?
a) Caput: caused by pressure on fetal head during labor, decreasing blood flow to the area and resulting in edema. Hematoma: caused by subperiosteal hemorrhage, usually resulting from a traumatic delivery.
b) Caput: soft, fluctuant, localized swelling with well-defined outline. Hematoma: localized but diffuse edema of the most dependent part, with poorly defined outline.
c) Caput: swelling does not cross suture lines, but may occur over more than one cranial bone. Hematoma: swelling crosses suture lines.
d) Caput: present at birth. Takes several weeks or months to disappear. Hematoma: appears after birth, increasing in size for 2-3 days. Disappears within a few hours up to several days.

Answer 84

A

Question 85

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

Answer 85

D

Question 86

357 . Which of the following fetal heart patterns does not indicate distress?
a) A sinusoidal pattern.
b) No observable variability and recurrent late or variable decelerations.
c) No observable variability until the fetus moves, when reactivity is seen.
d) No observable variability and bradycardia.

Answer 86

C

Question 87

358 . On inspection of the placenta, you discover that a part of the membranes is missing. The client has had very little bleeding, her vital signs are all within normal range, and her fundus is firm and at the umbilicus. Which of the following is not an appropriate management strategy?
a) Expectant management: tell the client what to expect and to watch for any signs of infection.
b) Perform intrauterine exploration to try to remove fragments.
c) Insert a sterile speculum and use facial tissue to collect membrane fragments hanging from the os.
d) Give the client medication or herbs to cause the uterus to contract, such as Angelica.

Answer 87

B

Question 88

359 . The neonate your client just delivered is not breathing and is flaccid. You dry the baby and stimulate it, but there’s no response, and so you suction mouth and then nose. This stimulates the neonate to start trying to breathe, and it starts gasping. You ensure the baby is warm, skin-to-skin with the mother. What do you do next?
a) Provide positive pressure ventilation.
b) Provide blow-by oxygen.
c) Start CPAP.
d) Start chest compressions and PPV in a ratio of 3:1

Answer 88

A

Question 89

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

Answer 89

D

Question 90

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

Answer 90

C

Question 91

362 . Which is not an accurate description of a degree of meconium staining of amniotic fluid?
a) Thick: medium dark green or brown with a consistency like pea soup - particulate, thick, sometimes viscous and opaque. If smeared across newsprint, it is impossible to read.
b) Terminal: meconium that is passed by the fetus at the time of demise.
c) Light: greenish-yellow, greenish or, occasionally brown, but is watery and translucent with no particulate matter. If smeared across newsprint, it could be easily read.
d) Moderate: darker fluid than light staining, that is watery and may or may not contain particles. If smeared across newsprint, it would be difficult to read.

Answer 91

B

Question 92

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

Answer 92

D

Question 93

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

Answer 93

C

Question 94

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

Answer 94

B

Question 95

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

Answer 95

A

Question 96

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

Answer 96

A

Question 97

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

Answer 97

D

Question 98

369 . Which of the following does not describe a technique that could be used to safely facilitate delivery of the placenta?
a) Changing position, particularly to a squat or on the toilet.
b) Encourage the client to bring awareness to the placenta and to focus on releasing and delivering it.
c) Performing cord traction while guarding the uterus, and only pulling between contractions.
d) Administration of non-allopathic treatments, such as Angelica Root, Shepherd’s Purse, Blue Cohosh and/or Red Raspberry Leaf.

Answer 98

C

Question 99

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

Answer 99

B

Question 100

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

Answer 100

A

Question 101

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

Answer 101

A

Question 102

373 . You’re giving your client instructions on care of her perineum postpartum. Which do you not recommend?
a) A sitz bath or herbal bath with calendula, comfrey, uva ursi, marshmallow, witch hazel and other healing herbs.
b) Wait for at least 6 weeks before beginning kegels.
c) Do not have intercourse for at least 6 weeks if there was a perineal tear.
d) Tylenol or homeopathic arnica can be taken for pain relief.

Answer 102

B

Question 103

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

Answer 103

D

Question 104

375 . Which recommendations regarding diet and hydration when breastfeeding are accurate?
a) People who are breastfeeding and have a family history of allergies should avoid all known allergens in their diets.
b) There is no increase required from non-pregnant/non-lactating calorie intake, but approximately 1 liter extra of fluid intake per day.
c) Compared to non-pregnant/non-lactating requirements, approximately 300-500 additional calories are needed each day, and about 1 liter extra of fluid intake.
d) People who are breastfeeding need an impeccable diet, as they could cause significant problems with the baby otherwise.

Answer 104

C

Question 105

376 . Which of the following reflexes has been accurately described?
a) Doll’s eye reflex: triggered when the neonate is supine and the head is turned to either side. The neonate’s eyes follow the movement of the head.
b) Prone crawl reflex: triggered when the neonate is placed prone on a flat surface. The neonate attempts to crawl forwards using arms and legs.
c) Asymmetrical tonic neck reflex: triggered by extending or flexing the neonate’s head. With extension, the arms are extended and legs flexed, and with flexion, the arms are flexed and the legs are extended.
d) Symmetrical tonic neck reflex: triggered by turning the head to one side. The neonate extends the arm and leg on the side the head is turned to and will flex those on the opposite side, appearing in a ‘fencer pose’.

Answer 105

B

Question 106

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

Answer 106

D

Question 107

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

Answer 107

C

Question 108

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

Answer 108

B

Question 109

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

Answer 109

D

Question 110

381 . Nyla has been in labor for 8 hours now. 2 hours ago, you performed a vaginal exam at her request because she was experiencing sacral pain and suspected a malpresentation of some kind; you discovered a nuchal hand. You attempted to correct this during first stage with position changes and manual techniques such as poking at the fingers, but were unsuccessful. Nyla is now in second stage and descent is very rapid. What should you do?
a) Have Nyla stand with one foot supported higher than the opposite knee as you press on the iliac crests in order to create enough space in the pelvis for the compound presentation.
b) Push the arm above the pelvic brim and hold it there until a contraction begins. As it builds, flatten your hand against the fetal head and slowly withdraw it.
c) Ask Nyla to slow her pushing and apply counter pressure to the hand or arm, and to the perineum to attempt to prevent or reduce tearing.
d) Have Nyla get into a birth pool so the water can help soften the perineum, as then she will be less likely to tear.

Answer 110

C

Question 111

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

Answer 111

D

Question 112

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

Answer 112

C

Question 113

384 . Which of the following statements about abnormal labor patterns is not accurate?
a) Changes of position, relaxation methods, Rebozo techniques, nipple stimulation, food and rehydration are management strategies that might help.
b) Measuring not just cervical dilation but also effacement will give you a full understanding of progress.
c) You should assess the “3 P’s”, namely passage, passenger and power, and should aim to identify the root cause of the abnormality.
d) Prolonged labor can lead to emotional issues, and an increased risk of infection, PPH, and VKDB.

Answer 113

B

Question 114

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

Answer 114

D

Question 115

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

Answer 115

C

Question 116

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

Answer 116

B

Question 117

388 . Which of the following is not part of the normal management of the neonate in the immediate postpartum?
a) Initiating breastfeeding, ensuring this has occurred prior to the 10-minute APGAR, if taking one.
b) Immediate assessment following birth, ensuring neonate is breathing well.
c) Placing the neonate on the birthing person’s abdomen, skin-to-skin.
d) Covering with warmed blankets, replacing as necessary.

Answer 117

A

Question 118

389 . Which of the following is not a way a midwife would normally try to facilitate maternal relaxation during labor?
a) Discussing as many possible complications as possible, and your actions, should they occur.
b) When the client has psychological issues, a visit in very early labor may be needed to give reassurance and help getting the client settled into labor.
c) Ask family and friends to leave the birth space to remove distractions, perhaps to run errands or to prepare food in another area.
d) Help the client organize the birth room so that it is neat, well-ventilated and aesthetically pleasing.

Answer 118

A

Question 119

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

Answer 119

A

Question 120

391 . Nawal (G5P4004) is birthing a fetus in full extension. Which of the following is not part of an appropriate management strategy?
a) Taking care of fetal eyes when performing vaginal exams.
b) Once mentum clears perineum, apply pressure to the posterior perineum and control head to facilitate gradual release of sinciput.
c) Apply fundal pressure to ensure the fetal face is held in full extension by the pelvic floor.
d) Put pressure on sinciput to maintain full extension, allowing the mentum to pass under the symphysis pubis.

Answer 120

C

Question 121

392 . Which of the following is not a possible alternative to suturing for perineal tears?
a) Japanese suture clips
b) Tissue adhesive/surgical glue
c) Seaweed
d) Ensure the area remains dry by not wearing underwear and by sitting with legs spread apart.

Answer 121

D

Question 122

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

Answer 122

D

Question 123

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

Answer 123

C

Question 124

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

Answer 124

B

Question 125

396 . Despite living almost across the street from a great hospital, Nel decided to have a home birth with a midwife. It was a beautiful birth in water, and she’s now in bed, nursing her baby. You’ve been waiting 45 minutes for the placenta to deliver, but there has been no sign of separation until now, when there is a sudden gush of blood. You estimate 750 ml. You apply cord traction whilst guarding the uterus, but there is no lengthening of the cord. There is a second gush of blood of around 400 ml. You administer medication. What should you do next?
a) Transport Nel to the hospital immediately.
b) Encourage breastfeeding or give Nel herbal or homeopathic remedies.
c) Perform manual removal of the placenta.
d) Apply stronger traction on the cord. It is imperative that you remove the placenta immediately.

Answer 125

A

Question 126

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

Answer 126

D

Question 127

398 . Which of the following statements about erythema toxicum neonatorum is inaccurate?
a) A benign condition that is self-limiting. Reassure parents.
b) Occurs in 50% or more of healthy neonates.
c) Appears first on the face, then spreads to trunk, limbs and, finally, to palms and soles.
d) Erythematous blotchy macules, papules or pustules.

Answer 127

C

Question 128

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

Answer 128

B

Question 129

400 . When checking the newborn’s palate, which of the following is not correct?
a) There should be a bluish line the length of the soft palate.
b) The palate should have no arch or minimal arching.
c) You should reglove before inserting a finger into the neonate’s mouth.
d) The palate should be intact with no cleft, notches, fistula or thinning.

Answer 129

A

Question 130

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

Answer 130

D

Question 131

402 . Hypospadias (abnormal ventral placement of the urethral opening) may have the urethral meatus located in all of these locations bar which?
a) Scrotal
b) Subcoronal
c) Midshaft
d) At the tip of the glans penis

Answer 131

D

Question 132

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

Answer 132

C

Question 133

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

Answer 133

B

Question 134

405 . Which of the following is an abnormal finding in the neonate?
a) 100 breaths heard in a full minute of auscultating.
b) Transient tachypnea or apnea, lasting less than 15 seconds.
c) Occasional rales heard.
d) Heart rate of 104 bpm.

Answer 134

A

Question 135

406 . Niamh is beginning to show signs that she’s in active labor, and is feeling very nauseous. She’s already had 1 episode of emesis, an hour ago, and has refused to eat or drink anything since. What do you do?
a) Explain the importance of food and fluid intake during labor, including for energy and maintaining electrolyte balances, as well as reducing the risk of ketosis, which can cause labor to slow. Recommend small sips and bites of food, and discuss stimulation of an appropriate acupressure point.
b) Explain that ketoacidosis is likely if she does not eat enough, and this is a medical emergency. Encourage her to eat a large meal, avoiding spicy or greasy food.
c) Explain that the act of vomiting can help dilate the cervix, and so she should keep eating.
d) Recommend that she drink plenty of water and avoid food, as the water will be easier on her stomach and it’s most important that she stay well-hydrated.

Answer 135

A

Question 136

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

Answer 136

D

Question 137

408 . Your client is hemorrhaging postpartum. You’ve checked for distended bladder and sequestered clots, and have decided to administer medication. Which of the following is not a correct dose and/or route?
a) 800 mcg Misoprostol rectally.
b) 0.2 mg (1 ml ampule) Methergine IM.
c) 1 mg (5 tablets) Methergine PO.
d) 10 units (1 ml) Pitocin IM, or 20-30 units in 500 ml IV solution IV.

Answer 137

C

Question 138

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

Answer 138

B

Question 139

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

Answer 139

A

Question 140

411 . Which is not a correct denominator for the following presenting parts?
a) Face: brow
b) Breech: sacrum
c) Shoulder: acromion
d) Vertex: occiput

Answer 140

A

Question 141

412 . Which of the following is not a benefit or risk associated specifically with birthing in water?
a) There is an increased risk of epidural or spinal anesthesia
b) It facilitates maternal movement and deeper relaxation
c) There is a risk of a waterborne infection and of a missed cord avulsion
d) It reduces the length of the first stage of labor

Answer 141

A

Question 142

413 . You’re considering various measures to support Nessa, who’s currently struggling with labor, and think through pros and cons of using a TENS machine, hot compress, sterile water papules, counter pressure on her lower back, or a knee press. Which complication is Nessa experiencing?
a) Fetus is in occiput posterior position.
b) Fetus is in a transverse lie.
c) Fetus is in complete breech presentation.
d) Fetus is in mentum anterior position.

Answer 142

A

Question 143

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

Answer 143

D

Question 144

415 . You’re performing a newborn exam on a neonate who cried spontaneously at birth and who has had good oxygen saturation levels since birth. You lift the baby to observe tone, and see that the arms both fell backwards a little, and the neonate seemed about to slip out of your hands. When you turn the baby to ventral suspension, there is an exaggerated convex curvature of the spine. How would you record the neonate’s tone in the chart, and what clinical significance is there?
a) The neonate has hypertonia. Since it is central, this implies that there was an episode of apnea and the neonate has hypoxic-ischemic encephalopathy.
b) The neonate has hypertonia. There are many possible causes of this, including systemic illness, neurological disorders and metabolic or genetic conditions.
c) The neonate has hypotonia. There are many possible causes of this, including systemic illness, neurological disorders and metabolic or genetic conditions.
d) The neonate has hypotonia. Since it is central, this implies that there was an episode of apnea and the neonate has hypoxic-ischemic encephalopathy.

Answer 144

C

Question 145

416 . You’re examining a neonate’s clavicles. Which of the following is a normal finding?
a) Symmetry, including of crepitus
b) Clavicle can be palpated easily and distinctly along its full length
c) Tenderness
d) Step-off on clavicle

Answer 145

B

Question 146

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

Answer 146

A

Question 147

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

Answer 147

A

Question 148

419 . Which of the following is not a recommended comfort measure for engorgement?
a) Take a warm shower and allow milk to run freely (massaging the breast if letdown is not spontaneous).
b) Cold compress/cabbage leaves after a feed.
c) Hand express briefly to reduce engorgement.
d) Pump breasts until there’s been no milk ejected for at least 5 minutes.

Answer 148

D

Question 149

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

Answer 149

C

Question 150

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

Answer 150

B

Question 151

422 . Which of the following observations of a female newborn’s genitalia is abnormal?
a) A flesh-colored, smooth-surfaced lesion protruding from the vagina
b) A small amount of bloody vaginal discharge is visualized
c) White vaginal secretions are visualized
d) Normal vaginal mucus bulges behind an imperforate hymen.

Answer 151

D

Question 152

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

Answer 152

D

Question 153

424 . You’re looking at a newborn’s spine for signs of any deformities. Which of the following is not a correct description of a congenital spinal deformity?
a) Scoliosis: The spine is curved laterally into a ‘C’ or ‘S’ shape.
b) Kyphosis: The upper spine has exaggerated curvature anteroposteriorly.
c) Spondylosis: The spine is curved anteroposteriorly into an ‘S’ shape.
d) Lordosis: The lower spine has exaggerated curvature anteroposteriorly.

Answer 153

C

Question 154

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

Answer 154

B

Question 155

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

Answer 155

A

Question 156

427 . Which of the following correctly lists the mechanism of descent and rotation for a fetus in breech presentation?
a) 1. Buttocks/feet emerge, SA. 2. Body restitutes to ST as trunk is born. 3. Legs release spontaneously. (Chest crease shows arms are not behind head.) 4. Fetus does tummy crunches to release arms and flex head. 5. Arms release spontaneously. (Full perineum shows head is flexed.) 6. Head releases spontaneously.
b) 1. Buttocks/feet emerge, ST. 2. Body restitutes to SA as trunk is born. 3. Legs release spontaneously. (Chest crease shows arms are not behind head.) 4. Fetus does tummy crunches to release arms and extend head. 5. Arms release spontaneously. (Full perineum shows head is extended.) 6. Head releases spontaneously.
c) 1. Buttocks/feet emerge, SA. 2. Body restitutes to ST as trunk is born. 3. Legs release spontaneously. (Chest crease shows arms are not behind head.) 4. Fetus does tummy crunches to release arms and extend head. 5. Arms release spontaneously. (Full perineum shows head is extended.) 6. Head releases spontaneously.
d) 1. Buttocks/feet emerge, ST. 2. Body restitutes to SA as trunk is born. 3. Legs release spontaneously. (Chest crease shows arms are not behind head.) 4. Fetus does tummy crunches to release arms and flex head. 5. Arms release spontaneously. (Full perineum shows head is flexed.) 6. Head releases spontaneously.

Answer 156

D

Question 157

428 . Which statement about a possible medication choice for PPH is not accurate?
a) Pitocin produces intermittent, regular, strong contractions.
b) Methergine produces long, sustained contractions.
c) Misoprostol given during the third stage of labor has the risk of causing placental entrapment.
d) Methergine given during the third stage of labor has the risk of causing placental entrapment.

Answer 157

C

Question 158

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

Answer 158

B

Question 159

430 . When examining a term newborn’s ears, which of these is an abnormal finding?
a) Each protrudes 2.5 cm (1”) from the head.
b) Ears spring back to position when moved forward gently.
c) Pinna is well-formed with defined curves in the upper part.
d) No preauricular pits or tags.

Answer 159

A

Question 160

431 . Grand multiparity, polyhydramnios, hypertension, smoking, multiple gestation. All of these predisposing factors are associated with which complication?
a) Preterm delivery.
b) Placental abruption.
c) Cord prolapse.
d) Placenta accreta.

Answer 160

B

Question 161

432 . You’re examining a newborn’s abdomen. You look at the abdomen while you wait for the baby to relax, and then gently palpate. Which of the following is a normal finding?
a) Liver edge 1-2 cm below right costal margin
b) Umbilical hernia
c) Spleen felt, with no abnormal masses
d) Umbilicus is midway between xiphoid process and pubis

Answer 161

A

Question 162

433 . Nat is experiencing a trickle bleed in the immediate postpartum. You estimate 450 ml of blood loss. You check her vital signs and discover that her blood pressure has dropped by approximately 40 points in both systolic and diastolic, her respiratory rate is 30 breaths per minute and her pulse is 126. What action is appropriate?
a) Transport Nat for signs of hypovolemic shock.
b) Start an IV and check vital signs again once the bag is finished.
c) Administer Pitocin or other antihemorrhagic and encourage Nat to drink.
d) Encourage Nat to breastfeed.

Answer 162

A

Question 163

434 . Which of the following best describes internal bimanual compression?
a) Stand between client’s legs. Insert dominant hand into the vagina, clenching the fist in the anterior fornix, as high above the cervix as possible. Place the open palm of the non-dominant hand over posterior side of the fundus and apply pressure caudally, compressing the uterus between the hands for at least 5 minutes or until uterus is contracted and bleeding is controlled.
b) Stand to the client’s side. Insert dominant hand into the vagina, then splay hand out in the anterior fornix, as high above the cervix as possible. Place the open palm of the non-dominant hand over posterior side of the fundus and apply pressure caudally, compressing the uterus between the hands for at least 5 minutes or until uterus is contracted and bleeding is controlled.
c) Stand to the client’s side. Insert dominant hand into the vagina, then splay hand out in the anterior fornix, as high above the cervix as possible. Place the open palm of the non-dominant hand over posterior side of the fundus and apply pressure caudally, compressing the uterus between the hands until the OB is ready to take over.
d) Stand between client’s legs. Insert dominant hand into the vagina, clenching the fist in the anterior fornix, as high above the cervix as possible. Place the open palm of the non-dominant hand over posterior side of the fundus and apply pressure caudally, compressing the uterus between the hands until the OB is ready to take over.

Answer 163

A

Question 164

435 . You’re starting an emergency IV on Nat for hypovolemia. Which of the following do you not do?
a) 1. Inspect the bag for leaks and expiration date. Ensure the fluid is a pale-yellow color and contains only minimal particulate matter.
b) 3. With a tourniquet 4-6” above insertion site, insert catheter, apply pressure to the vein and remove the stylet.
c) 2. Fill the drip chamber to 1/3, hang the bag, and prime the tubing.
d) 4. Attach tubing and open the slip-and-pinch clamp and fully open the roller clamp. Ensure there is a rapid flow into the drip chamber.

Answer 164

A

Question 165

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

Answer 165

D

Question 166

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

Answer 166

C

Question 167

438 . Which of the following is not a sign of possible achondroplasia?
a) Prominent forehead
b) Proximal phalanges lengthened; ring and middle finger angled in opposite directions
c) Disproportionately large head-to-body ratio
d) Shortened arms and legs, especially upper arm and leg; reduced range of motion

Answer 167

B

Question 168

439 . You’re palpating a neonate’s head. Which of these is a normal finding regarding the anterior fontanelle?
a) Diamond-shaped
b) Bulging
c) Over 6cm
d) Depressed

Answer 168

A

Question 169

440 . 18 hours into labor, you’re encouraging Nitsa to rest, eat and rehydrate. You also suggest homeopathic arnica or astragalus, and have discussed the possibility of transport if her pulse, BP or temperature continue to rise, if ketonuria worsens or if FHT are non-reassuring. What condition are you working to prevent?
a) Clinical exhaustion
b) Swollen anterior lip
c) Posterior fetal position
d) Deep transverse arrest

Answer 169

A

Question 170

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

Answer 170

D

Question 171

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

Answer 171

D

Question 172

443 . When examining the neonate for cyanosis, which of the following statements is not true?
a) Cyanosis is a blue to dusky hue.
b) Arterial blood oxygen content is normal in acrocyanosis, but decreased in central cyanosis.
c) In differential cyanosis and reverse differential cyanosis, either the lower part or the upper part, respectively, remains cyanotic, whilst the other part remains pink. Differential cyanosis indicates PPH and left-heart abnormalities, and reverse differential cyanosis occurs with a transposition of the great arteries.
d) To differentiate circumoral cyanosis from facial bruising (ecchymosis), apply pressure over the skin. This will blanch with bruising but not with cyanosis.

Answer 172

D

Question 173

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

Answer 173

D

Question 174

445 . When auscultating the lungs of a neonate, you position the stethoscope on the baby’s back, near each shoulder, and then at mid-back on either side. Which of these would be an abnormal finding?
a) No rattles or scratchy noises
b) Air resonates as in a hollow chamber
c) Breath sounds louder on the right side (i.e. the side further away from the heart)
d) Irregular rhythm

Answer 174

C

Question 175

446 . Which of the following is not a correct description of placental findings seen with the following scenarios?
a) Syphilis: large, pale yellowish-grey placenta.
b) Local uterine conditions causing undernourishment of the placenta: large placenta with multiple calcifications.
c) Severe maternal hypertension/preeclampsia/eclampsia: extensive infarcts.
d) Erythroblastosis: large placenta, paler than normal.

Answer 175

B

Question 176

447 . When testing newborn reflexes (including Moro, Babinski, plantar, palmar, grasp, rooting, sucking, stepping, and arm recoil) to assess central nervous system disorder, what are you testing for, and what constitutes an abnormal result?
a) Hyporeflexia, hyperreflexia and asymmetrical reflexes are all abnormal.
b) Hyporeflexia and hyperreflexia are abnormal.
c) Hyperreflexia and asymmetrical reflexes are abnormal.
d) Hyporeflexia and asymmetrical reflexes are abnormal.

Answer 176

A

Question 177

448 . You’re assisting Nila with the birth of her first child, and the head has just delivered. You check for a nuchal cord, and find one. Which of these is not an action you might need to take to deliver the body?
a) Loop a finger under the cord and slide it over the fetal head.
b) If the cord is tight and is preventing the birth of the body, clamp and cut it. Prepare for resuscitation.
c) Apply suprapubic pressure towards Nila’s back and in the lateral direction that adducts the shoulder, as this will help the fetus descend, and the cord will descend with it.
d) Press the baby’s head towards the maternal thigh or perineum and somersault the baby out.

Answer 177

C

Question 178

449 . Which of the following is not a life-threatening consequence of accidental IV injection of Lidocaine?
a) Cardiac arrhythmia or arrest
b) Urticaria
c) Respiratory arrest
d) Seizures

Answer 178

B

Question 179

450 . Which of these is a normal finding for a newborn’s mouth and lips?
a) Lips and mucous membranes are moist and pink.
b) Mucous membranes are moist and dusky in color. Lips are moist and pink.
c) Mucous membranes are moist, lips are dry. Both are pink.
d) Mucous membranes are moist and dusky in color. Lips are dry and pink.

Answer 179

A

Question 180

451 . Which of the following is not an assessment made to determine progress during the second stage?
a) Contraction pattern
b) Maternal vital signs.
c) Vaginal examination to assess fetal position, station, descent with pushing effort and adaptation to the pelvis (e.g. molding, caput)
d) Peak FHT location

Answer 180

B

Question 181

452 . When examining a male baby’s genitalia, you notice that the left side of the scrotum feels ‘full’, and it’s difficult to palpate the testis on that side. Which of the following is a possible diagnosis and description thereof?
a) Hydrocele: the prostate gland is protruding into the scrotum; usually transilluminates with light. Normally resolves within the first year or two of life.
b) The left testis has descended into the scrotum, but the right has not. An undescended testicle occurs with around 3% of male babies, and the testis normally descends within the first few months of life.
c) The right testis has descended into the scrotum, but the left has not. An undescended testicle occurs with around 3% of male babies, and the testis normally descends within the first few months of life.
d) Inguinal hernia: a segment of bowel is protruding into the scrotum; bowel sounds may be heard. The loop of bowel may become incarcerated and strangulate if not surgically repaired.

Answer 181

D

Question 182

453 . You’re telling your client about colostrum. Which of these is not a fact about it?
a) It’s all a newborn needs for the first couple of days.
b) It contains more protein, less fat, and more Vitamin A than mature milk, and normally looks yellow.
c) It normally lasts until day 5, when you start to transition to mature milk.
d) It has high levels of antibodies and lactobacilli, which boost the neonate’s immunity.

Answer 182

C

Question 183

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

Answer 183

B

Question 184

455 . You want to test whether a neonate responds to sound. What do you check for?
a) Does the neonate startle to sudden loud noises?
b) Does the neonate turn their head towards a sound?
c) Does the neonate turn their eyes towards sound?
d) Does a neonate cry when there is a sudden noise?

Answer 184

A

Question 185

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

Answer 185

B

Question 186

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

Answer 186

A

Question 187

458 . The newborn has a persistent high-pitched cry. Which of these statements is not a recognized possible reason for this?
a) Withdrawal from heroin, methadone or alcohol. Transport.
b) Prematurity. Recommend referral.
c) Neurologic or metabolic abnormalities. Transport.
d) Hypercalcemia or hyperglycemia. If prolonged, transport.

Answer 187

D

Question 188

459 . Your client is positive for chlamydia, and has decided they want erythromycin eye ointment prophylactically for their newborn. Which of these statements about this is not true?
a) Application should be delayed until after the first period of reactivity (i.e. when the alert newborn is searching for the faces of parents).
b) Irrigation after application is not necessary.
c) The same tube can be used on multiple infants.
d) You should use 0.5% erythromycin ointment, spreading a thin bead from the inner to outer canthus of each eye.

Answer 188

C

Question 189

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

Answer 189

B

Question 190

461 . Which of the following observations of genitalia would not be an indication of ambiguous genitalia?
a) Microclitoris
b) Bilateral undescended testes
c) Fused labia
d) Bifid scrotum

Answer 190

A

Question 191

462 . Your client is experiencing a major hemorrhage. The client has emptied her bladder, you’ve removed sequestered clots, massaged the uterus to stimulate contractions, have given antihemorrhagics and started an IV, and tried bimanual compression, but were unable to stop the hemorrhage. Your assistant has called for an ambulance, but you decide you need to perform external aortic compression while you await transport. What do you do?
a) Explain the procedure and why you need to do it, and ask for consent. Locate the femoral pulse in the inguinal area. Place your fist (thumb on the outside) on the umbilicus, arm perpendicular to the client’s abdomen. Press slowly downwards until the femoral pulse disappears, which shows that blood flow to the uterus has been slowed/stopped. Maintain pressure until blood flow is controlled or other measures can be taken.
b) Explain the procedure and why you need to do it, and ask for consent. Locate the popliteal pulse in the popliteal fossa. Place your fist (thumb on the outside) just above the symphysis pubis, arm perpendicular to the client’s abdomen. Press slowly downwards until the popliteal pulse disappears, which shows that blood flow to the uterus has been slowed/stopped. Maintain pressure until blood flow is controlled or other measures can be taken.
c) Explain the procedure and why you need to do it, and ask for consent. Locate the femoral pulse in the inguinal area. Place your fist (thumb on the outside) just above the symphysis pubis, arm perpendicular to the client’s abdomen. Press slowly downwards until the femoral pulse disappears, which shows that blood flow to the uterus has been slowed/stopped. Maintain pressure until blood flow is controlled or other measures can be taken.
d) Explain the procedure and why you need to do it, and ask for consent. Locate the popliteal pulse in the popliteal fossa. Place your fist (thumb on the outside) on the umbilicus, arm perpendicular to the client’s abdomen. Press slowly downwards until the popliteal pulse disappears, which shows that blood flow to the uterus has been slowed/stopped. Maintain pressure until blood flow is controlled or other measures can be taken.

Answer 191

A

Question 192

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

Answer 192

D

Question 193

464 . What happens to fundal height immediately after birth?
a) Immediately after birth, the fundus is globular and displaced laterally, normally to the right. On the first day postpartum, it relaxes and balloons above the umbilicus and feels ‘boggy’.
b) Immediately after birth, it’s approximately at the umbilicus. On the first day postpartum, it contracts down to approximately halfway between umbilicus and symphysis pubis.
c) Immediately after birth, the fundus is several centimeters above the umbilicus, but it then contracts on the first day postpartum and is at the level of the umbilicus.
d) Immediately after birth, the fundus is several centimeters below the umbilicus. On the first day postpartum, it relaxes slightly, and is at the level of the umbilicus.

Answer 193

D

Question 194

465 . Your client declined the GBS screen and antibiotics during labor. Which of the following is not a sign of GBS in the newborn?
a) Seizures
b) Respiratory distress (including grunting or tachypnea)
c) Difficulty maintaining temperature
d) Hypertonia

Answer 194

D

Question 195

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

Answer 195

C

Question 196

467 . During a newborn exam, you first align the anterior superior iliac spines and place medial side of ankles together and look from above, then place the neonate’s feet on the bed so that the thighs and the calves are adducted. What are you doing?
a) Performing the V-finger test; you’re checking for metatarsus adductus.
b) Performing the Allis test; you’re looking for limb length discrepancies.
c) Performing the Ortolani maneuver; you’re checking for congenital hip dysplasia.
d) Performing the Babinski test; you’re looking for CNS disorders.

Answer 196

B

Question 197

468 . When examining a newborn’s eyes, which of the following is a normal finding?
a) Inner canthal distance 1.5-2.5 cm (0.6-1”)
b) Blue sclera
c) Cloudy cornea
d) Brushfield spots (salt and pepper speckling of the iris)

Answer 197

A

Question 198

469 . Which of the following correctly describes the mechanisms of delivery for MA face presentation?
a) 1. Engagement of submentobregmatic diameter in oblique diameter of pelvic brim. 2. Descent (ongoing). 3. Extension of fetal neck. 4. Internal rotation of head 45 degrees to MA, releasing the chin from the symphysis pubis. 5. Extension delivers the head. 6. Restitution of the head 45 degrees so it is perpendicular to shoulders. 7. Internal rotation of shoulders to AP diameter (with corresponding external rotation of head). 8. Lateral flexion to release shoulders.
b) 1. Engagement of occipitofrontal diameter in oblique diameter of pelvic brim. 2. Descent (ongoing). 3. Extension of fetal neck. 4. Internal rotation of head 45 degrees to MA, releasing the chin from the symphysis pubis. 5. Extension delivers the head. 6. Restitution of the head 45 degrees so it is perpendicular to shoulders. 7. Internal rotation of shoulders to AP diameter (with corresponding external rotation of head). 8. Lateral flexion to release shoulders.
c) 1. Engagement of occipitofrontal diameter in oblique diameter of pelvic brim. 2. Descent (ongoing). 3. Extension of fetal neck. 4. Internal rotation of head 45 degrees to MA, releasing the chin from the symphysis pubis. 5. Flexion delivers the head. 6. Restitution of the head 45 degrees so it is perpendicular to shoulders. 7. Internal rotation of shoulders to AP diameter (with corresponding external rotation of head). 8. Lateral flexion to release shoulders.
d) 1. Engagement of submentobregmatic diameter in oblique diameter of pelvic brim. 2. Descent (ongoing). 3. Extension of fetal neck. 4. Internal rotation of head 45 degrees to MA, releasing the chin from the symphysis pubis. 5. Flexion delivers the head. 6. Restitution of the head 45 degrees so it is perpendicular to shoulders. 7. Internal rotation of shoulders to AP diameter (with corresponding external rotation of head). 8. Lateral flexion to release shoulders.

Answer 198

D

Question 199

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

Answer 199

C

Question 200

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

Answer 200

B

Question 201

472 . Select the appropriate course of action with all of the following birth defects, if discovered at the time of birth: cleft palate/lip with neonate unable to swallow, chromosomal anomaly suspected, e.g. Down’s syndrome, gastroschisis/omphalocele, neural tube defect, tracheoesophageal fistula.
a) Transport the neonate to the nearest hospital with a NICU.
b) Consult with a physician during next business hours.
c) Transport the neonate to the nearest hospital, regardless of whether there is a NICU.
d) Refer to pediatrician.

Answer 201

A

Question 202

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

Answer 202

B

Question 203

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

Answer 203

A

Question 204

475 . Which of the following is not a partial list of equipment that is all essential to have at a birth?
a) PPV equipment, bulb syringe, DeLee, stethoscope.
b) Sterile gloves, cord clamps/hemostats, blunt-end scissors.
c) Doppler, erythromycin eye ointment, antihemorrhagics, oxygen.
d) Receiving blanket, hat (or other means to keep the neonate warm).

Answer 204

C

Question 205

476 . When examining a neonate’s skin, which of these statements is inaccurate?
a) Cutis marmorata: a lace-like mottled coloring of the skin. This can be a benign reaction to the cold, but is associated with conditions including trisomies, systemic lupus erythematosus and congenital hypothyroidism.
b) Infantile hemangiomas: a benign tumor made up of blood vessels. These ‘strawberry birth marks’ are at maximal size at birth and then gradually involute through childhood.
c) Petechiae: scattered red dots. This can be associated with birth trauma, but is also a sign of neonatal alloimmune thrombocytopenia, perinatal asphyxia and DIC.
d) Harlequin phenomenon: there is a clear line of demarcation between an area of paleness and an area of redness. May be benign or an indication of polycythemia.

Answer 205

B

Question 206

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

Answer 206

A

Question 207

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

Answer 207

B

Question 208

479 . Which of the following does not describe a finding indicating probable developmental dysplasia of the hip?
a) Flex hips and knees to 90 degrees and place anterior pressure on the greater trochanters, gently abducting the legs. Does not reduce a dislocated hip.
b) Asymmetry of gluteal folds
c) The bent knees are adducted and then gentle posteriorly directed pressure is applied. Hip luxates.
d) Limb length discrepancy

Answer 208

A

Question 209

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

Answer 209

D