CNM – Certified Nurse-Midwife | Comprehensive
Study Guide, Practice Exam, Questions & Answers,
Exam Prep Test Bank, Women's Health, Pregnancy,
Antepartum Care, Labor & Delivery, Postpartum
Care, Newborn Assessment, High-Risk Obstetrics,
Pharmacology, Clinical Decision-Making, Detailed
Rationales, Complete Review
Question 1: A 32-year-old primigravida at 37 weeks gestation presents with a
blood pressure of 148/92 mmHg and 1+ proteinuria. She reports a persistent
headache and visual disturbances. Which of the following is the most
appropriate next step in management?
A. Prescribe oral labetalol and send her home for home blood pressure monitoring.
B. Administer a 500 mL fluid bolus of normal saline and recheck blood pressure in one
hour.
C. Administer magnesium sulfate for seizure prophylaxis and initiate antihypertensive
therapy.
D. Schedule an induction of labor for 48 hours after administering antenatal
corticosteroids.
CORRECT ANSWER: C. Administer magnesium sulfate for seizure prophylaxis
and initiate antihypertensive therapy.
Rationale: The patient is exhibiting signs of preeclampsia with severe features (severe
hypertension, proteinuria, headache, and visual disturbances). The immediate priority is
to prevent eclampsia by administering magnesium sulfate and to manage the
hypertension to reduce the risk of maternal stroke. Delivery is the definitive treatment,
but it should be initiated in a timely manner, not delayed by 48 hours solely for
corticosteroids unless indicated for fetal lung maturity in a preterm gestation, which this
patient is not. Antihypertensive therapy and seizure prophylaxis are the immediate next
steps.
Question 2: A patient at 40 weeks gestation is in the active phase of labor with
an epidural in place. Her cervix is 6 cm dilated, 100% effaced, and the fetus is
at 0 station. Fetal heart tracing is reassuring. Her blood pressure drops to
90/50 mmHg. Which action should the CNM prioritize?
A. Turn the patient to the left lateral position and administer an intravenous fluid bolus.
B. Discontinue the epidural infusion immediately.
C. Administer ephedrine 5 mg intravenously.
D. Prepare the patient for an emergency cesarean section.
CORRECT ANSWER: A. Turn the patient to the left lateral position and
administer an intravenous fluid bolus.
Rationale: The most likely cause of hypotension in a patient with an epidural is
aortocaval compression from the gravid uterus, exacerbated by sympathetic blockade
from the epidural. The first-line management is to position the patient on her left side to
,relieve compression on the vena cava and to administer an IV fluid bolus to increase
preload. This is a common and effective intervention for epidural-induced hypotension .
Discontinuing the epidural or administering vasopressors like ephedrine are not the
immediate first steps and would be considered if positional changes and fluids are
ineffective. Emergency cesarean is not indicated if the fetal heart tracing is reassuring
and hypotension responds to standard measures.
Question 3: A Certified Nurse-Midwife is providing care to a low-risk patient in
the second stage of labor. To minimize the risk of perineal trauma, which
technique is recommended?
A. Directing the patient to push forcefully with each contraction.
B. Applying warm compresses to the perineum during pushing and delivery.
C. Performing a routine mediolateral episiotomy to prevent an uncontrolled tear.
D. Using fundal pressure to assist with fetal descent.
CORRECT ANSWER: B. Applying warm compresses to the perineum during
pushing and delivery.
Rationale: Evidence supports the use of warm compresses applied to the perineum
during the second stage of labor to reduce the incidence of third- and fourth-degree
perineal lacerations . Controlled, directed pushing is generally preferred over forceful
Valsalva. Routine episiotomy is no longer standard of care, and mediolateral
episiotomies are associated with significant pain and blood loss. Fundal pressure is not
recommended and is associated with uterine rupture and other complications.
Question 4: A newborn is born at 39 weeks gestation via spontaneous vaginal
delivery. At 5 minutes of life, the infant is crying and has a heart rate of 140
bpm, good muscle tone, and acrocyanosis. What is the most appropriate
APGAR score assessment for this infant?
A. APGAR score of 7
B. APGAR score of 8
C. APGAR score of 9
D. APGAR score of 10
CORRECT ANSWER: C. APGAR score of 9
Rationale: The APGAR score is assessed at 1 and 5 minutes of life. This infant gets 2
points for Heart Rate (>100 bpm), 2 points for Respiratory Effort (crying), 2 points for
Muscle Tone (good), 1 point for Color (acrocyanosis is considered normal in the first few
minutes and scores 1), and 2 points for Reflex Irritability (crying). This gives a total of 9
points out of a possible 10. A score of 10 is assigned only if the infant is completely pink.
Question 5: A 28-year-old nulliparous patient at 20 weeks gestation presents
with a history of recurrent UTIs. Her current urinalysis is negative for
bacteria. To prevent future UTIs, which of the following is the most
appropriate evidence-based recommendation?
,A. Void immediately before intercourse and drink 2 liters of water daily.
B. Prescribe prophylactic antibiotics to be taken daily.
C. Initiate a course of cranberry supplements.
D. Perform a clean-catch urinalysis weekly.
CORRECT ANSWER: A. Void immediately before intercourse and drink 2 liters
of water daily.
Rationale: Behavioral modifications are the first-line recommendation for preventing
UTIs in pregnancy, especially for recurrent infections. Voiding before and after
intercourse and maintaining adequate hydration are evidence-based strategies.
Cranberry supplements have limited supporting evidence for UTI prevention, and
prophylactic antibiotics are not recommended as first-line therapy and should be
reserved for patients who fail behavioral modifications due to the risk of antibiotic
resistance.
Question 6: A woman at 28 weeks gestation reports feeling a sudden gush of
fluid from her vagina. On examination, the fluid is clear and pooling in the
vaginal vault. The patient is not having contractions. What is the most
appropriate initial diagnostic test to confirm a diagnosis of premature rupture
of membranes (PROM)?
A. Nitrazine paper test for vaginal pH
B. Cervical ultrasound to check cervical length
C. Non-stress test to assess fetal well-being
D. Fetal fibronectin test (fFN)
CORRECT ANSWER: A. Nitrazine paper test for vaginal pH
Rationale: The Nitrazine paper test is used to detect the presence of amniotic fluid,
which has a pH of 7.1–7.3. A positive result (pH > 6.5) supports a diagnosis of ROM.
While the fern test is also diagnostic, the nitrazine test is a common and immediate
point-of-care diagnostic tool. A cervical ultrasound is used to assess risk for preterm
birth, not to diagnose rupture of membranes. A non-stress test assesses fetal well-being
but does not diagnose ROM.
Question 7: During an initial prenatal visit, a 35-year-old G2P1 patient reports
a history of deep vein thrombosis (DVT) during her last pregnancy. She is
currently 10 weeks pregnant. What prophylactic measure is most appropriate
for this patient?
A. Low-dose aspirin 81 mg daily.
B. Prophylactic dose of low-molecular-weight heparin (LMWH).
C. Therapeutic dose of unfractionated heparin.
D. Strict bed rest and compression stockings.
CORRECT ANSWER: B. Prophylactic dose of low-molecular-weight heparin
(LMWH).
, Rationale: A history of a prior DVT is an indication for thromboprophylaxis during
pregnancy. LMWH is the preferred agent because it does not cross the placenta and has
a lower risk of heparin-induced thrombocytopenia compared to unfractionated heparin.
Low-dose aspirin is often used for preeclampsia prophylaxis but is not sufficient for DVT
prevention. Therapeutic doses are indicated for a current thrombosis, not for
prophylaxis alone.
Question 8: A 25-year-old G1P0 woman at 39 weeks gestation presents with
contractions every 2-3 minutes. She is 4 cm dilated and 80% effaced. Fetal
heart rate is 130 bpm with moderate variability. After performing a vaginal
exam, the CNM notes the membranes are intact. Which of the following is the
most appropriate intervention?
A. Perform an amniotomy to augment labor.
B. Administer oxytocin to augment labor.
C. Encourage ambulation and other upright positions.
D. Encourage the patient to remain in bed in a left lateral position.
CORRECT ANSWER: C. Encourage ambulation and other upright positions.
Rationale: This patient is in active labor with a reassuring fetal heart rate tracing. For a
low-risk patient with spontaneous onset of labor and no complications, promoting
ambulation and upright positions is an appropriate non-pharmacologic intervention to
facilitate descent and pain management . The other options are interventions that are
not indicated at this point. Labor augmentation should be reserved for cases of arrest of
dilation or descent, not routine active management.
Question 9: A postpartum patient who is breastfeeding reports breast
engorgement and is concerned about mastitis. Which of the following
instructions is most appropriate for the CNM to provide for prevention of
mastitis?
A. Ensure complete emptying of the breast at each feeding.
B. Decrease frequency of feedings to allow the breast to rest.
C. Apply ice packs to the breast before feedings.
D. Wear a tight-fitting supportive bra to reduce milk supply.
CORRECT ANSWER: A. Ensure complete emptying of the breast at each
feeding.
Rationale: Incomplete emptying of the breast is a primary risk factor for the
development of mastitis. Teaching the patient to ensure the breast is fully drained via
frequent and effective feedings is the cornerstone of prevention. Decreasing feeding
frequency leads to stasis and increases risk. Heat, not ice, is usually recommended
before feedings to facilitate let-down, and a supportive, not tight, bra is best.
Question 10: A patient at 32 weeks gestation has a fundal height measurement
of 29 cm. Based on this measurement, what is the most appropriate next step
for the CNM?
Study Guide, Practice Exam, Questions & Answers,
Exam Prep Test Bank, Women's Health, Pregnancy,
Antepartum Care, Labor & Delivery, Postpartum
Care, Newborn Assessment, High-Risk Obstetrics,
Pharmacology, Clinical Decision-Making, Detailed
Rationales, Complete Review
Question 1: A 32-year-old primigravida at 37 weeks gestation presents with a
blood pressure of 148/92 mmHg and 1+ proteinuria. She reports a persistent
headache and visual disturbances. Which of the following is the most
appropriate next step in management?
A. Prescribe oral labetalol and send her home for home blood pressure monitoring.
B. Administer a 500 mL fluid bolus of normal saline and recheck blood pressure in one
hour.
C. Administer magnesium sulfate for seizure prophylaxis and initiate antihypertensive
therapy.
D. Schedule an induction of labor for 48 hours after administering antenatal
corticosteroids.
CORRECT ANSWER: C. Administer magnesium sulfate for seizure prophylaxis
and initiate antihypertensive therapy.
Rationale: The patient is exhibiting signs of preeclampsia with severe features (severe
hypertension, proteinuria, headache, and visual disturbances). The immediate priority is
to prevent eclampsia by administering magnesium sulfate and to manage the
hypertension to reduce the risk of maternal stroke. Delivery is the definitive treatment,
but it should be initiated in a timely manner, not delayed by 48 hours solely for
corticosteroids unless indicated for fetal lung maturity in a preterm gestation, which this
patient is not. Antihypertensive therapy and seizure prophylaxis are the immediate next
steps.
Question 2: A patient at 40 weeks gestation is in the active phase of labor with
an epidural in place. Her cervix is 6 cm dilated, 100% effaced, and the fetus is
at 0 station. Fetal heart tracing is reassuring. Her blood pressure drops to
90/50 mmHg. Which action should the CNM prioritize?
A. Turn the patient to the left lateral position and administer an intravenous fluid bolus.
B. Discontinue the epidural infusion immediately.
C. Administer ephedrine 5 mg intravenously.
D. Prepare the patient for an emergency cesarean section.
CORRECT ANSWER: A. Turn the patient to the left lateral position and
administer an intravenous fluid bolus.
Rationale: The most likely cause of hypotension in a patient with an epidural is
aortocaval compression from the gravid uterus, exacerbated by sympathetic blockade
from the epidural. The first-line management is to position the patient on her left side to
,relieve compression on the vena cava and to administer an IV fluid bolus to increase
preload. This is a common and effective intervention for epidural-induced hypotension .
Discontinuing the epidural or administering vasopressors like ephedrine are not the
immediate first steps and would be considered if positional changes and fluids are
ineffective. Emergency cesarean is not indicated if the fetal heart tracing is reassuring
and hypotension responds to standard measures.
Question 3: A Certified Nurse-Midwife is providing care to a low-risk patient in
the second stage of labor. To minimize the risk of perineal trauma, which
technique is recommended?
A. Directing the patient to push forcefully with each contraction.
B. Applying warm compresses to the perineum during pushing and delivery.
C. Performing a routine mediolateral episiotomy to prevent an uncontrolled tear.
D. Using fundal pressure to assist with fetal descent.
CORRECT ANSWER: B. Applying warm compresses to the perineum during
pushing and delivery.
Rationale: Evidence supports the use of warm compresses applied to the perineum
during the second stage of labor to reduce the incidence of third- and fourth-degree
perineal lacerations . Controlled, directed pushing is generally preferred over forceful
Valsalva. Routine episiotomy is no longer standard of care, and mediolateral
episiotomies are associated with significant pain and blood loss. Fundal pressure is not
recommended and is associated with uterine rupture and other complications.
Question 4: A newborn is born at 39 weeks gestation via spontaneous vaginal
delivery. At 5 minutes of life, the infant is crying and has a heart rate of 140
bpm, good muscle tone, and acrocyanosis. What is the most appropriate
APGAR score assessment for this infant?
A. APGAR score of 7
B. APGAR score of 8
C. APGAR score of 9
D. APGAR score of 10
CORRECT ANSWER: C. APGAR score of 9
Rationale: The APGAR score is assessed at 1 and 5 minutes of life. This infant gets 2
points for Heart Rate (>100 bpm), 2 points for Respiratory Effort (crying), 2 points for
Muscle Tone (good), 1 point for Color (acrocyanosis is considered normal in the first few
minutes and scores 1), and 2 points for Reflex Irritability (crying). This gives a total of 9
points out of a possible 10. A score of 10 is assigned only if the infant is completely pink.
Question 5: A 28-year-old nulliparous patient at 20 weeks gestation presents
with a history of recurrent UTIs. Her current urinalysis is negative for
bacteria. To prevent future UTIs, which of the following is the most
appropriate evidence-based recommendation?
,A. Void immediately before intercourse and drink 2 liters of water daily.
B. Prescribe prophylactic antibiotics to be taken daily.
C. Initiate a course of cranberry supplements.
D. Perform a clean-catch urinalysis weekly.
CORRECT ANSWER: A. Void immediately before intercourse and drink 2 liters
of water daily.
Rationale: Behavioral modifications are the first-line recommendation for preventing
UTIs in pregnancy, especially for recurrent infections. Voiding before and after
intercourse and maintaining adequate hydration are evidence-based strategies.
Cranberry supplements have limited supporting evidence for UTI prevention, and
prophylactic antibiotics are not recommended as first-line therapy and should be
reserved for patients who fail behavioral modifications due to the risk of antibiotic
resistance.
Question 6: A woman at 28 weeks gestation reports feeling a sudden gush of
fluid from her vagina. On examination, the fluid is clear and pooling in the
vaginal vault. The patient is not having contractions. What is the most
appropriate initial diagnostic test to confirm a diagnosis of premature rupture
of membranes (PROM)?
A. Nitrazine paper test for vaginal pH
B. Cervical ultrasound to check cervical length
C. Non-stress test to assess fetal well-being
D. Fetal fibronectin test (fFN)
CORRECT ANSWER: A. Nitrazine paper test for vaginal pH
Rationale: The Nitrazine paper test is used to detect the presence of amniotic fluid,
which has a pH of 7.1–7.3. A positive result (pH > 6.5) supports a diagnosis of ROM.
While the fern test is also diagnostic, the nitrazine test is a common and immediate
point-of-care diagnostic tool. A cervical ultrasound is used to assess risk for preterm
birth, not to diagnose rupture of membranes. A non-stress test assesses fetal well-being
but does not diagnose ROM.
Question 7: During an initial prenatal visit, a 35-year-old G2P1 patient reports
a history of deep vein thrombosis (DVT) during her last pregnancy. She is
currently 10 weeks pregnant. What prophylactic measure is most appropriate
for this patient?
A. Low-dose aspirin 81 mg daily.
B. Prophylactic dose of low-molecular-weight heparin (LMWH).
C. Therapeutic dose of unfractionated heparin.
D. Strict bed rest and compression stockings.
CORRECT ANSWER: B. Prophylactic dose of low-molecular-weight heparin
(LMWH).
, Rationale: A history of a prior DVT is an indication for thromboprophylaxis during
pregnancy. LMWH is the preferred agent because it does not cross the placenta and has
a lower risk of heparin-induced thrombocytopenia compared to unfractionated heparin.
Low-dose aspirin is often used for preeclampsia prophylaxis but is not sufficient for DVT
prevention. Therapeutic doses are indicated for a current thrombosis, not for
prophylaxis alone.
Question 8: A 25-year-old G1P0 woman at 39 weeks gestation presents with
contractions every 2-3 minutes. She is 4 cm dilated and 80% effaced. Fetal
heart rate is 130 bpm with moderate variability. After performing a vaginal
exam, the CNM notes the membranes are intact. Which of the following is the
most appropriate intervention?
A. Perform an amniotomy to augment labor.
B. Administer oxytocin to augment labor.
C. Encourage ambulation and other upright positions.
D. Encourage the patient to remain in bed in a left lateral position.
CORRECT ANSWER: C. Encourage ambulation and other upright positions.
Rationale: This patient is in active labor with a reassuring fetal heart rate tracing. For a
low-risk patient with spontaneous onset of labor and no complications, promoting
ambulation and upright positions is an appropriate non-pharmacologic intervention to
facilitate descent and pain management . The other options are interventions that are
not indicated at this point. Labor augmentation should be reserved for cases of arrest of
dilation or descent, not routine active management.
Question 9: A postpartum patient who is breastfeeding reports breast
engorgement and is concerned about mastitis. Which of the following
instructions is most appropriate for the CNM to provide for prevention of
mastitis?
A. Ensure complete emptying of the breast at each feeding.
B. Decrease frequency of feedings to allow the breast to rest.
C. Apply ice packs to the breast before feedings.
D. Wear a tight-fitting supportive bra to reduce milk supply.
CORRECT ANSWER: A. Ensure complete emptying of the breast at each
feeding.
Rationale: Incomplete emptying of the breast is a primary risk factor for the
development of mastitis. Teaching the patient to ensure the breast is fully drained via
frequent and effective feedings is the cornerstone of prevention. Decreasing feeding
frequency leads to stasis and increases risk. Heat, not ice, is usually recommended
before feedings to facilitate let-down, and a supportive, not tight, bra is best.
Question 10: A patient at 32 weeks gestation has a fundal height measurement
of 29 cm. Based on this measurement, what is the most appropriate next step
for the CNM?
