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, Gynecologic Care, Fetal
Monitoring, Pharmacology, Clinical Judgment,
Detailed Rationales, Complete Review
Question 1: A 28-year-old primigravida at 10 weeks gestation presents with mild
vaginal spotting and cramping. Her vital signs are stable, and a transvaginal
ultrasound reveals an empty uterus with a complex adnexal mass. Her quantitative
serum β-hCG level is 1,500 mIU/mL. What is the most appropriate next step in
management?
A. Administer methotrexate immediately.
B. Perform a dilation and curettage (D&C).
C. Repeat the serum β-hCG level in 48 hours.
D. Admit for immediate laparoscopic surgery.
CORRECT ANSWER: C. Repeat the serum β-hCG level in 48 hours
Rationale:In a hemodynamically stable patient with a suspected ectopic pregnancy
and a β-hCG level below the discriminatory zone (typically 1,500-2,500 mIU/mL for a
visible intrauterine pregnancy), a single β-hCG level is insufficient for diagnosis. Serial
β-hCG measurements every 48 hours are essential to evaluate the rate of rise or fall,
which helps differentiate between a viable intrauterine pregnancy, a failing pregnancy,
and an ectopic pregnancy. A normal intrauterine pregnancy typically shows a 66% or
greater rise in 48 hours, while an abnormal rise or plateau is suggestive of an ectopic or
non-viable pregnancy. Medical management with methotrexate or surgical intervention
is not indicated without a confirmed diagnosis and shared decision-making .
Question 2: A 32-year-old G3P2 at 38 weeks gestation with a history of two prior
low-transverse cesarean sections is admitted in spontaneous labor. She is
requesting a trial of labor after cesarean (TOLAC). Which of the following findings
would be the strongest contraindication to proceeding with TOLAC?
A. Estimated fetal weight of 3,800 grams.
B. Maternal body mass index (BMI) of 32 kg/m².
C. A prior classical uterine incision.
D. An inter-delivery interval of 18 months.
CORRECT ANSWER: C. A prior classical uterine incision.
Rationale:A prior classical cesarean incision (a vertical incision into the upper,
contractile segment of the uterus) is an absolute contraindication to TOLAC due to a
significantly higher risk of uterine rupture, estimated at 4-9%, compared to 0.5-1% for a
low-transverse incision. Other factors like maternal obesity, estimated fetal weight, and
,a short inter-delivery interval are relative contraindications and increase risk, but they
do not preclude a TOLAC attempt entirely .
Question 3: A 25-year-old G1P0 at 32 weeks gestation presents with a 3-day history
of a painless, pruritic rash on her abdomen that has spread to her thighs and arms.
On examination, she has erythematous papules and plaques on her abdomen, with
sparing of the umbilicus. Which of the following is the most likely diagnosis?
A. Pemphigoid gestationis.
B. Intrahepatic cholestasis of pregnancy (ICP).
C. Pruritic urticarial papules and plaques of pregnancy (PUPPP).
D. Atopic eruption of pregnancy.
CORRECT ANSWER: C. Pruritic urticarial papules and plaques of pregnancy
(PUPPP).
Rationale:PUPPP, also known as polymorphic eruption of pregnancy, is the most
common dermatosis of pregnancy. It typically presents in the third trimester in
primigravidas with intensely pruritic, erythematous, urticarial papules and plaques that
start on the abdomen, often within striae, and spare the umbilicus. In contrast,
pemphigoid gestationis is a rare autoimmune blistering disorder that often involves the
umbilicus. ICP is characterized by pruritus without a primary rash and elevated serum
bile acids. Atopic eruption of pregnancy typically presents with eczematous lesions
earlier in pregnancy.
Question 4: A 29-year-old G2P1 at 35 weeks gestation presents with a blood
pressure of 155/100 mmHg and 3+ proteinuria on a urine dipstick. She reports a
headache and epigastric pain. Laboratory results show a platelet count of
85,000/µL, AST of 80 U/L, and ALT of 95 U/L. What is the most appropriate
immediate management?
A. Administer oral labetalol and send the patient home for bed rest.
B. Admit to the hospital for administration of magnesium sulfate and antihypertensives,
with a plan for delivery.
C. Administer betamethasone and plan for outpatient management with twice-weekly
fetal surveillance.
D. Initiate antihypertensive therapy and schedule an induction of labor for 37 weeks.
CORRECT ANSWER: B. Admit to the hospital for administration of magnesium
sulfate and antihypertensives, with a plan for delivery.
Rationale:This patient has severe preeclampsia with concerning features (severe-range
blood pressure, thrombocytopenia, elevated liver enzymes, and end-organ symptoms
like headache and epigastric pain). With a gestational age of 35 weeks, delivery is
indicated after maternal stabilization. Magnesium sulfate is the standard of care for
seizure prophylaxis, and antihypertensives like labetalol or hydralazine should be
administered to manage severe blood pressure . Corticosteroids for fetal lung maturity
,should also be administered, but the primary management is delivery due to the
severity of the maternal condition.
Question 5: A woman in active labor at 6 cm dilation has a category II fetal heart
rate tracing. She has recurrent late decelerations. What is the most appropriate
initial intervention for intrauterine resuscitation?
A. Perform an amnioinfusion.
B. Position the patient in the left lateral position, administer oxygen, and increase
intravenous fluids.
C. Administer a tocolytic agent.
D. Prepare for immediate cesarean delivery.
CORRECT ANSWER: B. Position the patient in the left lateral position, administer
oxygen, and increase intravenous fluids.
Rationale:The initial management of non-reassuring fetal heart rate patterns (category
II or III) involves maximizing maternal cardiac output and uterine blood flow. This is
achieved by positioning the patient in the left lateral decubitus position to relieve
aortocaval compression, administering supplemental oxygen to increase fetal
oxygenation, and increasing intravenous fluids to correct hypovolemia and improve
blood pressure. If these measures are ineffective, further interventions such as
amnioinfusion or tocolysis may be considered. Immediate cesarean delivery is
indicated if the pattern does not resolve with resuscitation or if there is a category III
tracing [citation:13, 14].
Question 6: A 34-year-old G1P0 at 20 weeks gestation receives her routine anatomy
ultrasound. The report notes a two-vessel umbilical cord. What is the most
appropriate next step in her management?
A. Reassure the patient that this is a benign finding with no associated risks.
B. Schedule a fetal echocardiogram to assess for cardiac anomalies.
C. Inform the patient and schedule a detailed fetal anatomy survey to evaluate for
associated congenital anomalies.
D. Order a maternal serum alpha-fetoprotein (MSAFP) screening test.
CORRECT ANSWER: C. Inform the patient and schedule a detailed fetal anatomy
survey to evaluate for associated congenital anomalies.
Rationale:A single umbilical artery (SUA) is a common finding, but it is associated with
an increased risk of fetal congenital anomalies, particularly renal, cardiovascular, and
gastrointestinal defects. The initial anatomy scan should be reviewed carefully and, if
necessary, a targeted or detailed ultrasound should be performed to rule out these
anomalies. While a fetal echocardiogram may be considered, a comprehensive
evaluation of all organ systems is the primary next step .
, Question 7: A 28-year-old primigravida at 12 weeks gestation has a routine prenatal
labs. Her blood type is O negative, and her antibody screen is negative. At what
gestational age should she receive Rh D immune globulin (RhoGAM)?
A. 24 weeks.
B. 28 weeks.
C. 32 weeks.
D. 36 weeks.
CORRECT ANSWER: B. 28 weeks.
Rationale:Standard prenatal prophylaxis with Rh D immune globulin (RhoGAM) is
recommended for all Rh-negative, unsensitized pregnant women at 28 weeks gestation
to prevent alloimmunization. It is also indicated within 72 hours after any potential
sensitizing event during pregnancy, such as vaginal bleeding, abortion, amniocentesis,
or trauma .
Question 8: A 22-year-old woman with type 1 diabetes mellitus is planning a
pregnancy. Her current HbA1c is 9.5%. Which of the following is the most important
preconception intervention to reduce her risk of fetal anomalies?
A. Begin folic acid 4 mg daily immediately.
B. Optimize glycemic control to achieve an HbA1c of <6.5% prior to conception.
C. Schedule a baseline ophthalmology and nephrology evaluation.
D. Refer for high-risk obstetric care at 8 weeks gestation.
CORRECT ANSWER: B. Optimize glycemic control to achieve an HbA1c of <6.5%
prior to conception.
Rationale:Periconceptional glycemic control is paramount in women with pre-existing
diabetes. Elevated HbA1c levels in the first trimester are strongly correlated with an
increased risk of congenital anomalies, particularly neural tube defects and cardiac
malformations. Achieving an HbA1c of less than 6.5% before conception is a primary
goal to reduce these risks. While high-dose folic acid (4 mg) and specialty evaluations
are also important, optimizing blood glucose is the most critical intervention .
Question 9: A woman at 41 weeks and 2 days gestation has an unfavorable cervix
(Bishop score of 3). She requests induction of labor. Which cervical ripening agent
is contraindicated in a patient with a prior cesarean section?
A. Membrane sweeping.
B. Misoprostol (prostaglandin E1).
C. Dinoprostone (prostaglandin E2) vaginal insert.
D. Mechanical cervical ripening with a Foley bulb.
CORRECT ANSWER: B. Misoprostol (prostaglandin E1).
Rationale:The use of misoprostol for cervical ripening and labor induction is
contraindicated in patients with a prior cesarean section or major uterine surgery due to
Study Guide, Practice Exam, Questions & Answers,
Exam Prep Test Bank, Women's Health, Prenatal
Care, Labor & Delivery, Postpartum Care, Newborn
Care, High-Risk Obstetrics, Gynecologic Care, Fetal
Monitoring, Pharmacology, Clinical Judgment,
Detailed Rationales, Complete Review
Question 1: A 28-year-old primigravida at 10 weeks gestation presents with mild
vaginal spotting and cramping. Her vital signs are stable, and a transvaginal
ultrasound reveals an empty uterus with a complex adnexal mass. Her quantitative
serum β-hCG level is 1,500 mIU/mL. What is the most appropriate next step in
management?
A. Administer methotrexate immediately.
B. Perform a dilation and curettage (D&C).
C. Repeat the serum β-hCG level in 48 hours.
D. Admit for immediate laparoscopic surgery.
CORRECT ANSWER: C. Repeat the serum β-hCG level in 48 hours
Rationale:In a hemodynamically stable patient with a suspected ectopic pregnancy
and a β-hCG level below the discriminatory zone (typically 1,500-2,500 mIU/mL for a
visible intrauterine pregnancy), a single β-hCG level is insufficient for diagnosis. Serial
β-hCG measurements every 48 hours are essential to evaluate the rate of rise or fall,
which helps differentiate between a viable intrauterine pregnancy, a failing pregnancy,
and an ectopic pregnancy. A normal intrauterine pregnancy typically shows a 66% or
greater rise in 48 hours, while an abnormal rise or plateau is suggestive of an ectopic or
non-viable pregnancy. Medical management with methotrexate or surgical intervention
is not indicated without a confirmed diagnosis and shared decision-making .
Question 2: A 32-year-old G3P2 at 38 weeks gestation with a history of two prior
low-transverse cesarean sections is admitted in spontaneous labor. She is
requesting a trial of labor after cesarean (TOLAC). Which of the following findings
would be the strongest contraindication to proceeding with TOLAC?
A. Estimated fetal weight of 3,800 grams.
B. Maternal body mass index (BMI) of 32 kg/m².
C. A prior classical uterine incision.
D. An inter-delivery interval of 18 months.
CORRECT ANSWER: C. A prior classical uterine incision.
Rationale:A prior classical cesarean incision (a vertical incision into the upper,
contractile segment of the uterus) is an absolute contraindication to TOLAC due to a
significantly higher risk of uterine rupture, estimated at 4-9%, compared to 0.5-1% for a
low-transverse incision. Other factors like maternal obesity, estimated fetal weight, and
,a short inter-delivery interval are relative contraindications and increase risk, but they
do not preclude a TOLAC attempt entirely .
Question 3: A 25-year-old G1P0 at 32 weeks gestation presents with a 3-day history
of a painless, pruritic rash on her abdomen that has spread to her thighs and arms.
On examination, she has erythematous papules and plaques on her abdomen, with
sparing of the umbilicus. Which of the following is the most likely diagnosis?
A. Pemphigoid gestationis.
B. Intrahepatic cholestasis of pregnancy (ICP).
C. Pruritic urticarial papules and plaques of pregnancy (PUPPP).
D. Atopic eruption of pregnancy.
CORRECT ANSWER: C. Pruritic urticarial papules and plaques of pregnancy
(PUPPP).
Rationale:PUPPP, also known as polymorphic eruption of pregnancy, is the most
common dermatosis of pregnancy. It typically presents in the third trimester in
primigravidas with intensely pruritic, erythematous, urticarial papules and plaques that
start on the abdomen, often within striae, and spare the umbilicus. In contrast,
pemphigoid gestationis is a rare autoimmune blistering disorder that often involves the
umbilicus. ICP is characterized by pruritus without a primary rash and elevated serum
bile acids. Atopic eruption of pregnancy typically presents with eczematous lesions
earlier in pregnancy.
Question 4: A 29-year-old G2P1 at 35 weeks gestation presents with a blood
pressure of 155/100 mmHg and 3+ proteinuria on a urine dipstick. She reports a
headache and epigastric pain. Laboratory results show a platelet count of
85,000/µL, AST of 80 U/L, and ALT of 95 U/L. What is the most appropriate
immediate management?
A. Administer oral labetalol and send the patient home for bed rest.
B. Admit to the hospital for administration of magnesium sulfate and antihypertensives,
with a plan for delivery.
C. Administer betamethasone and plan for outpatient management with twice-weekly
fetal surveillance.
D. Initiate antihypertensive therapy and schedule an induction of labor for 37 weeks.
CORRECT ANSWER: B. Admit to the hospital for administration of magnesium
sulfate and antihypertensives, with a plan for delivery.
Rationale:This patient has severe preeclampsia with concerning features (severe-range
blood pressure, thrombocytopenia, elevated liver enzymes, and end-organ symptoms
like headache and epigastric pain). With a gestational age of 35 weeks, delivery is
indicated after maternal stabilization. Magnesium sulfate is the standard of care for
seizure prophylaxis, and antihypertensives like labetalol or hydralazine should be
administered to manage severe blood pressure . Corticosteroids for fetal lung maturity
,should also be administered, but the primary management is delivery due to the
severity of the maternal condition.
Question 5: A woman in active labor at 6 cm dilation has a category II fetal heart
rate tracing. She has recurrent late decelerations. What is the most appropriate
initial intervention for intrauterine resuscitation?
A. Perform an amnioinfusion.
B. Position the patient in the left lateral position, administer oxygen, and increase
intravenous fluids.
C. Administer a tocolytic agent.
D. Prepare for immediate cesarean delivery.
CORRECT ANSWER: B. Position the patient in the left lateral position, administer
oxygen, and increase intravenous fluids.
Rationale:The initial management of non-reassuring fetal heart rate patterns (category
II or III) involves maximizing maternal cardiac output and uterine blood flow. This is
achieved by positioning the patient in the left lateral decubitus position to relieve
aortocaval compression, administering supplemental oxygen to increase fetal
oxygenation, and increasing intravenous fluids to correct hypovolemia and improve
blood pressure. If these measures are ineffective, further interventions such as
amnioinfusion or tocolysis may be considered. Immediate cesarean delivery is
indicated if the pattern does not resolve with resuscitation or if there is a category III
tracing [citation:13, 14].
Question 6: A 34-year-old G1P0 at 20 weeks gestation receives her routine anatomy
ultrasound. The report notes a two-vessel umbilical cord. What is the most
appropriate next step in her management?
A. Reassure the patient that this is a benign finding with no associated risks.
B. Schedule a fetal echocardiogram to assess for cardiac anomalies.
C. Inform the patient and schedule a detailed fetal anatomy survey to evaluate for
associated congenital anomalies.
D. Order a maternal serum alpha-fetoprotein (MSAFP) screening test.
CORRECT ANSWER: C. Inform the patient and schedule a detailed fetal anatomy
survey to evaluate for associated congenital anomalies.
Rationale:A single umbilical artery (SUA) is a common finding, but it is associated with
an increased risk of fetal congenital anomalies, particularly renal, cardiovascular, and
gastrointestinal defects. The initial anatomy scan should be reviewed carefully and, if
necessary, a targeted or detailed ultrasound should be performed to rule out these
anomalies. While a fetal echocardiogram may be considered, a comprehensive
evaluation of all organ systems is the primary next step .
, Question 7: A 28-year-old primigravida at 12 weeks gestation has a routine prenatal
labs. Her blood type is O negative, and her antibody screen is negative. At what
gestational age should she receive Rh D immune globulin (RhoGAM)?
A. 24 weeks.
B. 28 weeks.
C. 32 weeks.
D. 36 weeks.
CORRECT ANSWER: B. 28 weeks.
Rationale:Standard prenatal prophylaxis with Rh D immune globulin (RhoGAM) is
recommended for all Rh-negative, unsensitized pregnant women at 28 weeks gestation
to prevent alloimmunization. It is also indicated within 72 hours after any potential
sensitizing event during pregnancy, such as vaginal bleeding, abortion, amniocentesis,
or trauma .
Question 8: A 22-year-old woman with type 1 diabetes mellitus is planning a
pregnancy. Her current HbA1c is 9.5%. Which of the following is the most important
preconception intervention to reduce her risk of fetal anomalies?
A. Begin folic acid 4 mg daily immediately.
B. Optimize glycemic control to achieve an HbA1c of <6.5% prior to conception.
C. Schedule a baseline ophthalmology and nephrology evaluation.
D. Refer for high-risk obstetric care at 8 weeks gestation.
CORRECT ANSWER: B. Optimize glycemic control to achieve an HbA1c of <6.5%
prior to conception.
Rationale:Periconceptional glycemic control is paramount in women with pre-existing
diabetes. Elevated HbA1c levels in the first trimester are strongly correlated with an
increased risk of congenital anomalies, particularly neural tube defects and cardiac
malformations. Achieving an HbA1c of less than 6.5% before conception is a primary
goal to reduce these risks. While high-dose folic acid (4 mg) and specialty evaluations
are also important, optimizing blood glucose is the most critical intervention .
Question 9: A woman at 41 weeks and 2 days gestation has an unfavorable cervix
(Bishop score of 3). She requests induction of labor. Which cervical ripening agent
is contraindicated in a patient with a prior cesarean section?
A. Membrane sweeping.
B. Misoprostol (prostaglandin E1).
C. Dinoprostone (prostaglandin E2) vaginal insert.
D. Mechanical cervical ripening with a Foley bulb.
CORRECT ANSWER: B. Misoprostol (prostaglandin E1).
Rationale:The use of misoprostol for cervical ripening and labor induction is
contraindicated in patients with a prior cesarean section or major uterine surgery due to
