CNM – Certified Nurse-Midwife | Comprehensive Study
Guide, Practice Exam, Questions & Answers, Exam
Prep Test Bank, Women's Health, Prenatal Care, Labor
& Delivery, Postpartum Care, Newborn Care, High-Risk
Obstetrics, Gynecology, Fetal Monitoring, Clinical
Judgment, Detailed Rationales, Complete Review
Question 1: A 28-year-old primigravida at 10 weeks gestation presents with
mild vaginal spotting and stable vital signs. Her abdominal exam is
unremarkable, and a urine pregnancy test is positive. What is the most
appropriate next step in management?
A. Immediate transvaginal ultrasound to confirm viability
B. Serum quantitative beta-hCG measurement with a repeat in 48 hours
C. Administration of methotrexate for a suspected ectopic pregnancy
D. Reassurance and discharge home without further testing
CORRECT ANSWER: B. Serum quantitative beta-hCG measurement with a
repeat in 48 hours
Rationale:In a patient with a positive pregnancy test and vaginal bleeding, the
differential includes a viable intrauterine pregnancy, a nonviable pregnancy, or an
ectopic pregnancy. When the ultrasound is not immediately diagnostic, serial
quantitative beta-hCG levels are the most reliable method to differentiate between these
possibilities. A normally rising beta-hCG (at least 66% over 48 hours) suggests a viable
intrauterine pregnancy, while a suboptimal rise or a decline indicates a failing pregnancy
or an ectopic pregnancy. This approach is standard and is supported by the AMCB test
content outline, which emphasizes the importance of ordering and evaluating serial hCG
levels when indicated .
Question 2: A 32-year-old G3P2 at 38 weeks gestation with diet-controlled
gestational diabetes mellitus has an estimated fetal weight at the 97th
percentile on ultrasound. What is the most appropriate recommendation for
this patient?
A. Immediate cesarean delivery due to suspected fetal macrosomia
B. Elective induction of labor at 39 weeks with a planned vaginal delivery if the cervix is
favorable
C. Expectant management until 41 weeks gestation
D. Administration of antenatal corticosteroids and delivery at 39 weeks
CORRECT ANSWER: B. Elective induction of labor at 39 weeks with a planned
vaginal delivery if the cervix is favorable
Rationale:For patients with gestational diabetes complicated by suspected fetal
macrosomia, induction of labor at 39 weeks is a reasonable recommendation to reduce
the risk of further fetal growth and potential birth trauma, provided the cervix is
favorable. Immediate cesarean delivery is not indicated solely for a large estimated fetal
weight. Expectant management beyond 39 weeks in a patient with diabetes and
,macrosomia can increase the risk of shoulder dystocia. Corticosteroids are not indicated
for this patient as they are used to accelerate fetal lung maturity in preterm labor. This
management strategy is a key component of care for deviations from normal
pregnancy .
Question 3: A newborn is delivered vaginally at 39 weeks to a mother who
tested positive for Group B Streptococcus (GBS) and received intrapartum
penicillin G only 1 hour prior to delivery. The newborn is vigorous with Apgar
scores of 8 and 9. What is the appropriate management for this newborn?
A. Routine newborn care without further intervention or antibiotics
B. Admit to the Neonatal Intensive Care Unit (NICU) for empirical IV antibiotics
C. Obtain a complete blood count (CBC), blood culture, and observe closely for 48 hours
D. Administer intramuscular antibiotics to the newborn immediately
CORRECT ANSWER: C. Obtain a complete blood count (CBC), blood culture,
and observe closely for 48 hours
Rationale:Neonates born to GBS-positive mothers who received less than 4 hours of
intrapartum antibiotic prophylaxis are at increased risk for early-onset GBS disease.
According to established guidelines, these infants should undergo limited evaluation,
which includes a CBC and blood culture, and be monitored closely for 48 hours for signs
of sepsis. Empirical antibiotics are reserved for symptomatic infants or those with
positive cultures. This management plan balances the risk of infection with the benefit of
avoiding unnecessary antibiotic exposure .
Question 4: A 25-year-old woman with a past medical history of breast cancer
diagnosed within the last 6 months is seeking contraception. Which of the
following contraceptive methods is contraindicated for this patient?
A. Copper Intrauterine Device (IUD)
B. Levonorgestrel-releasing Intrauterine System (LNG-IUS)
C. Depot medroxyprogesterone acetate (DMPA)
D. Combined Oral Contraceptive Pills (COCs)
CORRECT ANSWER: D. Combined Oral Contraceptive Pills (COCs)
Rationale:Combined oral contraceptives contain estrogen, which is contraindicated in
women with a current or recent history of breast cancer due to the hormone-sensitive
nature of many breast cancers. Estrogen can potentially stimulate tumor growth.
Progestin-only methods, such as the LNG-IUS, DMPA, and the copper IUD, are generally
considered safe alternatives for these patients. This clinical scenario highlights the need
for CNMs to assess medical history thoroughly when counseling about contraception .
Question 5: A 29-year-old woman at 35 weeks gestation is diagnosed with
severe preeclampsia. What is the most appropriate initial management plan
for this patient?
,A. Immediate induction of labor with continuous fetal monitoring and magnesium
sulfate for seizure prophylaxis
B. Outpatient management with strict blood pressure monitoring and bi-weekly
antenatal testing
C. Administration of oral antihypertensives and discharge with a plan for reevaluation in
72 hours
D. Immediate cesarean delivery without attempting labor induction
CORRECT ANSWER: A. Immediate induction of labor with continuous fetal
monitoring and magnesium sulfate for seizure prophylaxis
Rationale:For severe preeclampsia at or beyond 34 weeks, delivery is generally
recommended after maternal stabilization. The standard of care includes inducing labor
and administering magnesium sulfate to prevent eclampsia. Outpatient management is
not safe for severe preeclampsia. Immediate cesarean delivery is not the first line of
management unless there are obstetric indications or the patient cannot be stabilized.
This clinical scenario is a common focus in CNM exam preparation .
Question 6: A 26-year-old woman at 28 weeks gestation presents with new-
onset generalized pruritus that is worse at night. She has no rash. Laboratory
results show elevated serum bile acids. What is the most likely diagnosis and
the associated fetal risk?
A. Intrahepatic Cholestasis of Pregnancy (ICP) with an increased risk of fetal distress
and stillbirth
B. Preeclampsia with an increased risk of maternal seizure
C. HELLP syndrome with an increased risk of maternal hepatic rupture
D. Atopic eruption of pregnancy with no significant fetal risk
CORRECT ANSWER: A. Intrahepatic Cholestasis of Pregnancy (ICP) with an
increased risk of fetal distress and stillbirth
Rationale:The classic presentation of intrahepatic cholestasis of pregnancy is pruritus,
which can be generalized and worse at night, in the absence of a rash, along with
elevated serum bile acids. ICP is associated with significant fetal risks, including
meconium passage, fetal distress, preterm birth, and stillbirth. Prompt diagnosis and
management (e.g., ursodeoxycholic acid and early delivery) are crucial. This condition is
a key deviation from normal pregnancy that CNMs must identify .
Question 7: A postpartum patient on day 2 develops a fever of 38.8°C, uterine
tenderness, and foul-smelling lochia. What is the most appropriate
management for this patient?
A. Initiate broad-spectrum intravenous antibiotics and monitor for response, suspecting
endometritis
B. Provide reassurance as these are normal findings in the early postpartum period
C. Perform an immediate hysterectomy for suspected uterine rupture
D. Administer non-steroidal anti-inflammatory drugs (NSAIDs) and discharge home
, CORRECT ANSWER: A. Initiate broad-spectrum intravenous antibiotics and
monitor for response, suspecting endometritis
Rationale:The triad of fever, uterine tenderness, and foul lochia in the postpartum
period is highly suggestive of endometritis, a common postpartum infection. Prompt
initiation of broad-spectrum intravenous antibiotics is the standard of care. This is not a
normal postpartum finding and requires immediate treatment to prevent complications
such as sepsis. This question tests the CNM's ability to identify and manage postpartum
complications .
Question 8: A 34-year-old woman with a history of three consecutive first-
trimester spontaneous abortions is being evaluated for recurrent pregnancy
loss. Which diagnostic test is the most appropriate initial evaluation to assess
for uterine anomalies?
A. Hysterosalpingography (HSG) or saline infusion sonohysterography (SIS)
B. Parental karyotype analysis
C. Serum TSH level
D. Day 21 progesterone level
CORRECT ANSWER: A. Hysterosalpingography (HSG) or saline infusion
sonohysterography (SIS)
Rationale:Uterine anomalies, such as a septate or bicornuate uterus, are a known cause
of recurrent pregnancy loss. HSG and SIS are valuable imaging tools to evaluate the
uterine cavity shape and detect congenital anomalies or acquired lesions like fibroids
and polyps. While other tests like karyotyping and hormonal assessments are part of the
workup, imaging of the uterine anatomy is a primary step in the evaluation of recurrent
loss .
Question 9: A 33-year-old woman at 39 weeks gestation in active labor has a
Category II fetal heart tracing with repetitive late decelerations. What is the
immediate priority action for the CNM?
A. Continue routine monitoring as Category II tracings are benign
B. Initiate intrauterine resuscitation, including repositioning the patient, administering
oxygen, increasing IV fluids, and stopping oxytocin
C. Proceed directly to an emergency cesarean delivery without attempting resuscitation
D. Apply a fetal scalp electrode to obtain a more accurate tracing
CORRECT ANSWER: B. Initiate intrauterine resuscitation, including
repositioning the patient, administering oxygen, increasing IV fluids, and
stopping oxytocin
Rationale:A Category II fetal heart tracing is indeterminate and not predictive of fetal
acidosis. However, when it is accompanied by repetitive late decelerations, it warrants
immediate intervention. Intrauterine resuscitation is the standard first-line response to
improve uteroplacental perfusion and fetal oxygenation. This includes maternal
repositioning, oxygen administration, IV fluid bolus, and discontinuation of oxytocin. If
Guide, Practice Exam, Questions & Answers, Exam
Prep Test Bank, Women's Health, Prenatal Care, Labor
& Delivery, Postpartum Care, Newborn Care, High-Risk
Obstetrics, Gynecology, Fetal Monitoring, Clinical
Judgment, Detailed Rationales, Complete Review
Question 1: A 28-year-old primigravida at 10 weeks gestation presents with
mild vaginal spotting and stable vital signs. Her abdominal exam is
unremarkable, and a urine pregnancy test is positive. What is the most
appropriate next step in management?
A. Immediate transvaginal ultrasound to confirm viability
B. Serum quantitative beta-hCG measurement with a repeat in 48 hours
C. Administration of methotrexate for a suspected ectopic pregnancy
D. Reassurance and discharge home without further testing
CORRECT ANSWER: B. Serum quantitative beta-hCG measurement with a
repeat in 48 hours
Rationale:In a patient with a positive pregnancy test and vaginal bleeding, the
differential includes a viable intrauterine pregnancy, a nonviable pregnancy, or an
ectopic pregnancy. When the ultrasound is not immediately diagnostic, serial
quantitative beta-hCG levels are the most reliable method to differentiate between these
possibilities. A normally rising beta-hCG (at least 66% over 48 hours) suggests a viable
intrauterine pregnancy, while a suboptimal rise or a decline indicates a failing pregnancy
or an ectopic pregnancy. This approach is standard and is supported by the AMCB test
content outline, which emphasizes the importance of ordering and evaluating serial hCG
levels when indicated .
Question 2: A 32-year-old G3P2 at 38 weeks gestation with diet-controlled
gestational diabetes mellitus has an estimated fetal weight at the 97th
percentile on ultrasound. What is the most appropriate recommendation for
this patient?
A. Immediate cesarean delivery due to suspected fetal macrosomia
B. Elective induction of labor at 39 weeks with a planned vaginal delivery if the cervix is
favorable
C. Expectant management until 41 weeks gestation
D. Administration of antenatal corticosteroids and delivery at 39 weeks
CORRECT ANSWER: B. Elective induction of labor at 39 weeks with a planned
vaginal delivery if the cervix is favorable
Rationale:For patients with gestational diabetes complicated by suspected fetal
macrosomia, induction of labor at 39 weeks is a reasonable recommendation to reduce
the risk of further fetal growth and potential birth trauma, provided the cervix is
favorable. Immediate cesarean delivery is not indicated solely for a large estimated fetal
weight. Expectant management beyond 39 weeks in a patient with diabetes and
,macrosomia can increase the risk of shoulder dystocia. Corticosteroids are not indicated
for this patient as they are used to accelerate fetal lung maturity in preterm labor. This
management strategy is a key component of care for deviations from normal
pregnancy .
Question 3: A newborn is delivered vaginally at 39 weeks to a mother who
tested positive for Group B Streptococcus (GBS) and received intrapartum
penicillin G only 1 hour prior to delivery. The newborn is vigorous with Apgar
scores of 8 and 9. What is the appropriate management for this newborn?
A. Routine newborn care without further intervention or antibiotics
B. Admit to the Neonatal Intensive Care Unit (NICU) for empirical IV antibiotics
C. Obtain a complete blood count (CBC), blood culture, and observe closely for 48 hours
D. Administer intramuscular antibiotics to the newborn immediately
CORRECT ANSWER: C. Obtain a complete blood count (CBC), blood culture,
and observe closely for 48 hours
Rationale:Neonates born to GBS-positive mothers who received less than 4 hours of
intrapartum antibiotic prophylaxis are at increased risk for early-onset GBS disease.
According to established guidelines, these infants should undergo limited evaluation,
which includes a CBC and blood culture, and be monitored closely for 48 hours for signs
of sepsis. Empirical antibiotics are reserved for symptomatic infants or those with
positive cultures. This management plan balances the risk of infection with the benefit of
avoiding unnecessary antibiotic exposure .
Question 4: A 25-year-old woman with a past medical history of breast cancer
diagnosed within the last 6 months is seeking contraception. Which of the
following contraceptive methods is contraindicated for this patient?
A. Copper Intrauterine Device (IUD)
B. Levonorgestrel-releasing Intrauterine System (LNG-IUS)
C. Depot medroxyprogesterone acetate (DMPA)
D. Combined Oral Contraceptive Pills (COCs)
CORRECT ANSWER: D. Combined Oral Contraceptive Pills (COCs)
Rationale:Combined oral contraceptives contain estrogen, which is contraindicated in
women with a current or recent history of breast cancer due to the hormone-sensitive
nature of many breast cancers. Estrogen can potentially stimulate tumor growth.
Progestin-only methods, such as the LNG-IUS, DMPA, and the copper IUD, are generally
considered safe alternatives for these patients. This clinical scenario highlights the need
for CNMs to assess medical history thoroughly when counseling about contraception .
Question 5: A 29-year-old woman at 35 weeks gestation is diagnosed with
severe preeclampsia. What is the most appropriate initial management plan
for this patient?
,A. Immediate induction of labor with continuous fetal monitoring and magnesium
sulfate for seizure prophylaxis
B. Outpatient management with strict blood pressure monitoring and bi-weekly
antenatal testing
C. Administration of oral antihypertensives and discharge with a plan for reevaluation in
72 hours
D. Immediate cesarean delivery without attempting labor induction
CORRECT ANSWER: A. Immediate induction of labor with continuous fetal
monitoring and magnesium sulfate for seizure prophylaxis
Rationale:For severe preeclampsia at or beyond 34 weeks, delivery is generally
recommended after maternal stabilization. The standard of care includes inducing labor
and administering magnesium sulfate to prevent eclampsia. Outpatient management is
not safe for severe preeclampsia. Immediate cesarean delivery is not the first line of
management unless there are obstetric indications or the patient cannot be stabilized.
This clinical scenario is a common focus in CNM exam preparation .
Question 6: A 26-year-old woman at 28 weeks gestation presents with new-
onset generalized pruritus that is worse at night. She has no rash. Laboratory
results show elevated serum bile acids. What is the most likely diagnosis and
the associated fetal risk?
A. Intrahepatic Cholestasis of Pregnancy (ICP) with an increased risk of fetal distress
and stillbirth
B. Preeclampsia with an increased risk of maternal seizure
C. HELLP syndrome with an increased risk of maternal hepatic rupture
D. Atopic eruption of pregnancy with no significant fetal risk
CORRECT ANSWER: A. Intrahepatic Cholestasis of Pregnancy (ICP) with an
increased risk of fetal distress and stillbirth
Rationale:The classic presentation of intrahepatic cholestasis of pregnancy is pruritus,
which can be generalized and worse at night, in the absence of a rash, along with
elevated serum bile acids. ICP is associated with significant fetal risks, including
meconium passage, fetal distress, preterm birth, and stillbirth. Prompt diagnosis and
management (e.g., ursodeoxycholic acid and early delivery) are crucial. This condition is
a key deviation from normal pregnancy that CNMs must identify .
Question 7: A postpartum patient on day 2 develops a fever of 38.8°C, uterine
tenderness, and foul-smelling lochia. What is the most appropriate
management for this patient?
A. Initiate broad-spectrum intravenous antibiotics and monitor for response, suspecting
endometritis
B. Provide reassurance as these are normal findings in the early postpartum period
C. Perform an immediate hysterectomy for suspected uterine rupture
D. Administer non-steroidal anti-inflammatory drugs (NSAIDs) and discharge home
, CORRECT ANSWER: A. Initiate broad-spectrum intravenous antibiotics and
monitor for response, suspecting endometritis
Rationale:The triad of fever, uterine tenderness, and foul lochia in the postpartum
period is highly suggestive of endometritis, a common postpartum infection. Prompt
initiation of broad-spectrum intravenous antibiotics is the standard of care. This is not a
normal postpartum finding and requires immediate treatment to prevent complications
such as sepsis. This question tests the CNM's ability to identify and manage postpartum
complications .
Question 8: A 34-year-old woman with a history of three consecutive first-
trimester spontaneous abortions is being evaluated for recurrent pregnancy
loss. Which diagnostic test is the most appropriate initial evaluation to assess
for uterine anomalies?
A. Hysterosalpingography (HSG) or saline infusion sonohysterography (SIS)
B. Parental karyotype analysis
C. Serum TSH level
D. Day 21 progesterone level
CORRECT ANSWER: A. Hysterosalpingography (HSG) or saline infusion
sonohysterography (SIS)
Rationale:Uterine anomalies, such as a septate or bicornuate uterus, are a known cause
of recurrent pregnancy loss. HSG and SIS are valuable imaging tools to evaluate the
uterine cavity shape and detect congenital anomalies or acquired lesions like fibroids
and polyps. While other tests like karyotyping and hormonal assessments are part of the
workup, imaging of the uterine anatomy is a primary step in the evaluation of recurrent
loss .
Question 9: A 33-year-old woman at 39 weeks gestation in active labor has a
Category II fetal heart tracing with repetitive late decelerations. What is the
immediate priority action for the CNM?
A. Continue routine monitoring as Category II tracings are benign
B. Initiate intrauterine resuscitation, including repositioning the patient, administering
oxygen, increasing IV fluids, and stopping oxytocin
C. Proceed directly to an emergency cesarean delivery without attempting resuscitation
D. Apply a fetal scalp electrode to obtain a more accurate tracing
CORRECT ANSWER: B. Initiate intrauterine resuscitation, including
repositioning the patient, administering oxygen, increasing IV fluids, and
stopping oxytocin
Rationale:A Category II fetal heart tracing is indeterminate and not predictive of fetal
acidosis. However, when it is accompanied by repetitive late decelerations, it warrants
immediate intervention. Intrauterine resuscitation is the standard first-line response to
improve uteroplacental perfusion and fetal oxygenation. This includes maternal
repositioning, oxygen administration, IV fluid bolus, and discontinuation of oxytocin. If
