4. Prenatal (61-135)

Question 1

61 . Which of the following would not cause protein to be present in a urine sample?
a) Preeclampsia
b) Hypotension
c) Excessive exercise
d) UTI

Answer 1

B

Question 2

62 . Which of the following is most accurate?
a) Passage through the intestinal tract is slowed during pregnancy due to oxytocin relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
b) Passage through the intestinal tract is slowed during pregnancy due to progesterone relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
c) Passage through the intestinal tract is slowed during pregnancy due to estrogen relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.
d) Passage through the intestinal tract is slowed during pregnancy due to hCG relaxing smooth muscles. This additionally means that more water is absorbed from the indigestible material, which can lead to constipation. Increased fiber and adequate hydration are key.

Answer 2

B

Question 3

63 . Karen’s 32-week urine dipstick with first morning urine shows 70+ leukocytes, negative for nitrites, urobilinogen, protein, blood, ketones, bilirubin and glucose, a specific gravity of 1.015 and a pH of 6.5. She reports higher than prepregnancy frequency, but has nothing else to report. What (if any) is the significance of the leukocytes, and in what way should Karen respond, if at all?
a) Karen is showing signs that she’s heading towards preeclampsia, and so you should recommend herbal treatments to help reduce that risk.
b) Leukocyte spill into urine is normal in pregnancy because of the increased blood volume and an increased burden on the kidneys.
c) Since this was a clean catch, the leukocytes must have come from the urine, showing that Karen is fighting an infection in her urinary tract.
d) The lack of nitrites or symptoms of a UTI and the fact that this appears not to have been a clean catch urine test all mean that evidence of a UTI is weak. Karen should produce a clean catch and you should test again before making recommendations for combating a UTI.

Answer 3

D

Question 4

64 . Leanne has symptoms of a vaginal yeast infection, but has declined allopathic treatment. Which of these would you not recommend to her?
a) Wear cotton underwear, or no underwear at all. If wearing a pantyliner, get a breathable one and change it regularly.
b) Try inserting boric acid suppositories, which prevent candida fungi from growing, or taking oral fluconazole.
c) Taking garlic (in food, ideally not heavily cooked, or in tablet or capsule form), or even inserting a whole, un-nicked clove vaginally may help. Remove a clove from the vagina if it causes a burning sensation, and change 3 times a day if not.
d) Take a high-quality probiotic such as Lactobacillus rhamnosus or Lactobacillus acidophilus.

Answer 4

B

Question 5

65 . At a prenatal appointment, you ask Judith to look at your pen point as you hold it about 2 feet from her face. You then move it towards her nose, carefully watching her eyes. What are you doing, and why?
a) Watching for the divergence of the eyes and contraction of irises as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
b) Watching for the divergence of the eyes and dilation of pupils as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
c) Watching for the convergence of the eyes and dilation of irises as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.
d) Watching for the convergence of the eyes and contraction of pupils as she looks at the object closer to her - one sign of accommodation. If absent, there are many causes, including trauma and pharmacological agents, so you’d need to investigate further.

Answer 5

D

Question 6

66 . Kim has glucose in her urine, as shown on the dipstick test you just did, but no other signs or symptoms of diabetes. Which is not an appropriate suggestion for supporting her kidney health while you investigate further?
a) Beet juice and pumpkin seeds
b) Juniper
c) Nettle leaf infusion
d) Lemon juice and cranberry juice

Answer 6

B

Question 7

67 . At 38 weeks, Jerry confides in you that they’re worried they won’t be able to chestfeed because their chest isn’t big enough to produce enough milk for a baby. You ask to see Jerry’s chest and see no signs of insufficient glandular tissue/hypoplasia. Which of these might you have just seen?
a) Asymmetry between the two areas of glandular tissue, with one side much larger than the other
b) A ‘tube sock’ appearance, with no discernible growth or change during pregnancy
c) Areolas swollen or puffy
d) A narrow gap between the areas of glandular tissue

Answer 7

D

Question 8

68 . Which complication are these all risk factors for: Smoking, stress, poor nutrition, periodontal disease, UTI, genital tract infection, multiple gestation, prior preterm birth, prior cervical surgery?
a) Systemic infection
b) Preterm birth
c) Preeclampsia
d) Placental abruption

Answer 8

B

Question 9

69 . Jen complains that she isn’t sleeping well, and asks for recommendations of herbs or medications she might take to help with this. Which of these would not help with insomnia?
a) Skullcap
b) Yerba mate
c) Chamomile
d) Hops

Answer 9

B

Question 10

70 . You’re attempting to assess fetal flexion by performing Leopold’s Maneuvers. Which of these statements is not true?
a) If no cephalic prominence is felt, there is neither flexion nor extension, and the fetus is in military position.
b) If the cephalic prominence is on the same side as the fetal back, the fetal head is extended, and the fetus has either brow or face presentation.
c) If the cephalic prominence is on the same side as the small parts, the fetus is well-flexed and the fetus is in vertex position.
d) The third maneuver (or Pawlik’s grip) is used to ascertain fetal flexion, whereby the thumb and fingers of the dominant hand are placed just above the pubic symphysis and the presenting part is grasped.

Answer 10

D

Question 11

71 . Macaah calls at 34.2 weeks to report definite rupture of membranes. What is the most appropriate course of action?
a) Advise Macaah to monitor the amniotic fluid. If it develops a foul odor, they should be referred to a physician.
b) Advise impeccable hygiene, good hydration, and a healthful diet. If Macaah reports signs of infection, refer them to a physician.
c) Start a course of antibiotics to prevent fetal infection and practice expectant management.
d) Refer Macaah for steroids, antibiotics and continued care.

Answer 11

D

Question 12

72 . At her 34 week appointment, you’re palpating Maxine’s abdomen when you feel a contraction building from her lower uterine segment up to the fundus. You ask Maxine about it, who says she can’t feel it very strongly, but she has noticed a few of them recently. Which of the following is the best course of action?
a) Consult with a chiropractor who is certified in the Webster Technique about whether an adjustment might help Maxine in such a way that the fetus might be better able to get into an optimal position.
b) Tell Maxine that these ‘toning contractions’ are called Braxton Hicks and she’ll probably feel a lot more of them from now on. Explain that they’ll be more common when her bladder is full or, conversely, when she’s dehydrated, and exercise and bumpy car rides often trigger them too.
c) Consult an obstetrician because you suspect preterm labor. They may be able to provide medications to stall labor if you act quickly.
d) Suggest that Maxine should pack her bag for the birth center and get the baby’s car seat in soon because this is a sign that she might go into labor sooner rather than later.

Answer 12

C

Question 13

73 . Which of the following is not a good recommendation for mitigating sciatica?
a) Try to sit down as much as possible, as this can reduce the inflammation of the sciatic nerve.
b) Yoga stretches such as alternating cat/cow and child’s pose can relieve the pain.
c) Chiropractic care may help realign pelvic joints, and a massage can help reduce inflammation (both should be with providers trained in care during pregnancy).
d) Heat or cold applied to the area can help ease the discomfort.

Answer 13

A

Question 14

74 . In a first trimester appointment with Meghan, you’re discussing exercise and ask about any separation of her abdominal muscles that she was told about after her last pregnancy. She says her doctor told her she had 3 fingers’ breadth of separation at one of her postpartum appointments. Which exercise is least likely to help prevent pathological diastasis recti with this pregnancy?
a) “Hug your baby”: try lifting your belly button towards your spine so you’re hugging your baby using only your tummy muscles.
b) Engaging the pelvic floor and deepest layer of abdominal muscles (transverse abdominals) before moving. Roll to your side before sitting up.
c) Lifting weights and doing crunches in second and third trimesters.
d) Sitting on a birth ball, hands on knees. Scooping in your abdomen and rolling back, easing off if you see a triangular shape forming on your belly.

Answer 14

C

Question 15

75 . Kamala is 32 weeks pregnant, and has been having trouble sleeping. Which of these would you not tell her?
a) Practicing deep relaxation can help, as can use of essential oils such as lavender.
b) Half a dropperful of skullcap, valerian or hops may help.
c) Exercising can help. But not right before bed, as it can make the baby more active, increasing insomnia.
d) Ensure you always lie on your back when trying to sleep, as this can rapidly decrease blood pressure so you can relax and sleep better.

Answer 15

D

Question 16

76 . At 24 weeks, Mandy presents with signs and symptoms of candidiasis. She states that she doesn’t want to use allopathic medication because she worries it would harm the baby, but seems very reluctant to try non-allopathic remedies either. She tells you she can cope with the symptoms, so wants to just let it ‘run its course’. You tell her of the pros and cons of this, including risks for not treating it. Which of these was on your list for the latter part?
a) Placental abruption
b) Pyelonephritis
c) UTI
d) Preterm birth

Answer 16

D

Question 17

77 . What is the normal pattern of blood pressure change during pregnancy?
a) A pathologic decrease in the second trimester due to maternal anemia, and then a rise to approximately baseline due to blood volume increase.
b) A physiologic decrease in the second trimester, caused by dilation of blood vessels, and then a rise to approximately baseline in third trimester, caused by blood volume expansion.
c) A physiologic increase in the second trimester, caused by increased blood volume, and then a fall to approximately baseline in the third trimester due to dilation of blood vessels.
d) A pathologic increase in the second trimester due to blood vessel constriction, and then a fall to approximately baseline due to vasodilation.

Answer 17

B

Question 18

78 . When Jaqueline’s baby is born, she comments on the shape of his head, worried that he might be brain-damaged. Which is most accurate?
a) During labor and birth, the baby’s head normally ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. In fact, the bones of a baby’s skull are designed to do this: they can overlap slightly, making the head smaller in certain places so that it can better fit through the pelvis.
b) During labor and birth, the baby’s head often ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. It’s called a caput succedaneum, and will disappear in a couple of days with no lasting damage.
c) During labor and birth, the baby’s head normally ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. In fact, the bones of a baby’s skull are designed to do this: they can separate slightly as they are pushed out of place by the bony pelvis.
d) During labor and birth, the baby’s head normally ‘molds’ to the shape of the passageway, and this doesn’t cause any damage to the brain. In fact, the bones of a baby’s skull are designed to do this: they can move slightly without having any negative impact on the brain.

Answer 18

A

Question 19

79 . Leticia, who had an OB care for her until 23 weeks, joined your practice at 28 weeks. Since then, she has had the following fundal heights: 28 weeks: 25 cm, 30 weeks: 26 cm, 32 weeks: 27 cm. On palpation, amniotic fluid levels appear normal and the fetus feels small for gestational age, though possibly with a normally-sized head. The head is still high. You referred Leticia for an ultrasound when she first joined your practice, and refer for a second one now. Which is the best explanation for why?
a) You suspect that the fetus is constitutionally small for gestational age, but need to rule out congenital anomalies to ensure it remains safe for out of hospital birth.
b) You suspect that the fetus is constitutionally small for gestational age, but need to monitor placental health to ensure the fetus remains safe for out of hospital birth.
c) You suspect that the fetus has intrauterine growth restriction. To differentiate this from a fetus that is small for gestational age, serial ultrasounds are required. If present, there are significant risks to the fetus, and referral to an obstetrician is appropriate.
d) You suspect that the fetus has intrauterine growth restriction. To differentiate this from a fetus that is small for gestational age, the IUGR fetus will measure below the 5th percentile for weight for that gestational age. If present, there are significant risks to the fetus, and referral to an obstetrician is appropriate.

Answer 19

C

Question 20

80 . Which of the following is not a probable contraindication for out of hospital VBAC?
a) Previous vertical cesarean section.
b) Previous inverted T cesarean section.
c) Several prior cesarean sections.
d) Cesarean repaired with double-layer closure.

Answer 20

D

Question 21

81 . Lana’s blood pressure has been slowly rising for the last 3 visits, creeping up from 110/72 at her intake appointment at 10 weeks to 132/84 now, at 30 weeks. Which of these is not an appropriate suggestion for what she should do?
a) Add a calcium/magnesium/potassium supplement and drink hops or passionflower tea.
b) Ensure she’s eating enough protein, and eliminate caffeine from her diet.
c) Exercise for at least 30 minutes daily and work on meditation and stress reduction.
d) Drink 3 glasses of orange juice daily, and take bitter orange or guarana supplements.

Answer 21

D

Question 22

82 . You’ve been monitoring Jaylin’s weight throughout pregnancy, and it’s been increasing an average of 2 to 3 lb every month. Today, she’s in for her 30 week appointment. What do you expect?
a) Her weight will probably have increased by around 2 or 3 lb, since that’s her norm. If it’s gone up a little more, ask about her diet to see if there’s anything she can improve.
b) Her weight will probably have increased by at least 5 lb due to blood volume expansion. If it hasn’t, ask questions about her diet to try to determine whether she has reduced plasma expansion, which carries an increased risk of complications such as preeclampsia.
c) You probably won’t ask her to weigh herself today, as weight checks cause anxiety with no health benefit, and Jaylin has been doing very well so far.
d) Her weight will probably have increased by 4 or 5 lb, as the baby is growing very fast at this stage. If not, you expect to see a big jump at her next appointment.

Answer 22

B

Question 23

83 . You’ve read that open-ended questions are good in some situations. What is an example, and when is an appropriate time for its use?
a) Has your husband ever physically assaulted you? Asked to help identify abuse.
b) How much water did you drink yesterday? Asked to determine whether client is sufficiently hydrating.
c) Can you tell me about the dietary supplements you took this week? Asked to determine whether client started taking floradix.
d) Can you tell me about your homelife? Asked to help understand psycho-social health and emotional wellbeing.

Answer 23

D

Question 24

84 . What is cholestasis?
a) Thyroxine flow is suppressed or blocked, resulting in permanent damage to the thyroid gland and a reduction in the amount of thyroxine released into the blood.
b) Bile flow is suppressed or blocked, resulting in the destruction of the liver cell membranes by bile acids, releasing bile acids into the blood.
c) Lymph flow is suppressed or blocked, resulting in swollen lymph nodes and the release of lymph into the blood.
d) Insulin flow is suppressed or blocked, resulting in pancreatitis and release of an excess of insulin into the blood.

Answer 24

B

Question 25

85 . Which of the following is not a normal change during pregnancy?
a) Intensely itchy palms of hands and soles of feet.
b) Lumbar lordosis
c) Increased vaginal discharge
d) Postcoital spotting

Answer 25

A

Question 26

86 . Which of the following non-allopathic methods would not be appropriate for attempting to turn a breech presentation to cephalic?
a) Moxibustion sticks.
b) Acupuncture or massage.
c) Pulsatilla 30X and chiropractic adjustment.
d) Belly binding.

Answer 26

D

Question 27

87 . Which of these do you not need to be able to inform clients about for local options for cesarean birth?
a) The cost
b) Which is the closest (at different times of day and with different traffic conditions)
c) Which have immediate emergency access and which have an on-call OB who might be away from the hospital
d) Which has more OBs that practice there

Answer 27

D

Question 28

88 . Which of the following is not a potential management or treatment method for cholestasis?
a) Elective cesarean or induction after 36 or 37 weeks.
b) Eating a diet high in fats, warm baths, tight-fitting clothes.
c) Water-soluble Vitamin K (possibly only appropriate for clients with prolonged prothrombin time).
d) Ursodiol (prescription medication), cool or oatmeal baths.

Answer 28

B

Question 29

89 . Which is a reasonable ‘rule of thumb’ for the odor of urine?
a) Sweet smell implies diabetes is likely. Unpleasant smell indicates infection of some kind.
b) Sweet smell implies preeclampsia. Unpleasant smell implies candida.
c) Sweet smell suggests cystic fibrosis. Unpleasant smell is normal in pregnancy.
d) Sweet smell is normal. Unpleasant smell indicates an STI.

Answer 29

A

Question 30

90 . Which of the following does not describe a presentation of placental abruption?
a) Complete: the entire placenta detaches from the uterine wall. Symptoms are massive bleeding, pain and fetal demise.
b) Hidden: center of placenta separates from uterine wall, with all edges remaining attached so that bleeding is contained behind the placenta. Severe uterine pain, fetal distress and a ‘woody’-feeling abdomen on palpation are the primary s/s. The fetus may survive if delivered immediately.
c) Subchorionic hematoma: an accumulation of blood between the uterine wall and the gestational membranes, including the placenta. The primary symptom is spotting or bleeding. Most result in uncomplicated pregnancies.
d) Partial: an edge of the placenta separates from the uterine wall. Symptoms are pain and bleeding. The fetus may survive if delivered immediately.

Answer 30

C

Question 31

91 . At 38 weeks, you discover that Lee’s fetus is ROP. Which of these is not a technique you should encourage her to try in order to help with rotation to the anterior?
a) Lie on your back, head down, on a plank or ironing board propped up on a sofa. Do this for up to 20 minutes 1-3 times a day.
b) Straddle an armless chair, facing its back, and rest your arms on the chair’s back. Move your bottom back to the edge of the seat and lean forwards so your belly hangs low. Relax your abdominal muscles and maintain this for 20 minutes 4 to 6 times a day.
c) Do pelvic rocks (cat-cows) for 10 minutes 6 to 8 times a day.
d) See a chiropractor for an adjustment.

Answer 31

A

Question 32

92 . Which statement about exercise during pregnancy is not accurate?
a) Avoid stress on abdominal muscles and jerky motions, to reduce the risk of diastasis recti.
b) Since joints and ligaments are looser and hence more susceptible to injury during pregnancy, don’t aim for maximum resistance.
c) Take care not to get dehydrated, and pay attention to your body and its limits.
d) Kegels and squats are not recommended during pregnancy, as they tighten the pelvic floor, leading to potential dystocia.

Answer 32

D

Question 33

93 . At 10 weeks, Linore calls you to tell you she has vaginal bleeding and worries she’s having a miscarriage. Which of these is not an alternative diagnosis that springs to your mind?
a) Fibroids
b) Placenta previa with cervical change
c) Vaginal infection
d) Subchorionic hemorrhage

Answer 33

B

Question 34

94 . Juli is 28, G3P2002, and had her intake appointment with you a couple of days ago at 37.1 weeks. Your physical assessment found nothing of note beyond mild edema in her ankles. Her urine dipstick showed trace protein. Her BP was 126/78, pulse was 76, and temperature was 97.5. Fundal height was 36 cm, with the fetus LOA and FHR 132-146. The OB panel is back, and there was nothing of significance. She’s A+. You’ve not yet obtained Juli’s records, as she says her OB’s is “being difficult” about releasing them. You’ve never had an issue with this OB before, so expect to receive records soon. That evening, Juli calls to tell you she’s in labor. How do you feel?
a) Very concerned. You haven’t seen prenatal records, and so have no proof she even had prenatal care. She may have placenta previa for all you know! You plan to change your protocols after this.
b) Excited for the birth, but fully aware of the fact that Juli has had a term loss, and may therefore have a dysfunctional labor. You haven’t had much time to work on this with Juli, but you have tricks up your sleeve, so expect things will go OK.
c) You’re slightly concerned about the fundal height being low, and worry there might be undiagnosed oligohydramnios. You’d planned to send her for an ultrasound as soon as possible to confirm or rule this out. You plan to continue care with Juli, but will have all resuscitation equipment prepped and ready, just in case the baby has trouble transitioning after birth.
d) You’re very worried because she has signs of preeclampsia, and you know there are significant risks to both Juli and her baby. You plan to monitor her blood pressure carefully, and will transfer her at the first sign of it creeping up.

Answer 34

A

Question 35

95 . Kehlani is 40 weeks, and is recapping normal fetal activity and fetal kick counts with you. Which of these questions of hers has ‘no’ as an answer?
a) If baby kicks and then immediately hits me, does that still count as 1 movement for the kick count?
b) Is it OK if there are gaps of half an hour or so where I don’t feel baby move at all?
c) Do hiccups count when I’m adding up kicks?
d) Should baby move more after I’ve drunk a glass of juice?

Answer 35

C

Question 36

96 . You’ve asked Marge to do daily kick counts, timing how long it takes to feel 10 separate movements at approximately the same time every day, after a meal. Today, at 41w6d, she calls you to tell you that the time it’s taken over the last 3 days has increased from 13 minutes to 21 minutes and now to 36 minutes. What is your recommendation?
a) Although the time it’s taken to count 10 movements has increased, it’s still far less than an hour, and so there is no cause for concern. Continue expectant management.
b) Marge should be transferred to the hospital for an emergency cesarean section.
c) A reduction in fetal movement is normal post term, and of no clinical concern. Continue expectant management.
d) Marge should be referred for a biophysical profile to assess fetal wellbeing, as decreased fetal movement is strongly correlated with fetal demise, especially post term.

Answer 36

D

Question 37

97 . Melissa admits to you at 16 weeks that she’s started smoking again, and asks what the risks to the baby are. You tell her that it exposes the baby to toxins such as lead, cadmium, cyanide, nicotine and carbon monoxide, that the baby’s blood flow is reduced, limiting the delivery of oxygen and nutrients, resulting in impaired growth and development. It significantly increases the risk of miscarriage, stillbirth, abnormalities with the placenta, IUGR and neonatal death. Which of the following did you forget?
a) Low birth weight
b) Preterm delivery
c) Macrosomia
d) Post term delivery

Answer 37

B

Question 38

98 . You’re showing your client a model of a placenta, umbilical cord, and membranes, to help explain the anatomy and physiology of pregnancy. What do you point out?
a) The outer membrane, called the chorion, and inner membrane, called the amnion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 vein and 2 arteries.
b) The outer membrane, called the amnion, and inner membrane, called the chorion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 vein and 2 arteries.
c) The outer membrane, called the amnion, and inner membrane, called the chorion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 artery and 2 veins.
d) The outer membrane, called the chorion, and inner membrane, called the amnion. The lumpy outer maternal side of the placenta and smooth, membrane-covered inner fetal side of the placenta. The umbilical cord, which has 1 artery and 2 veins.

Answer 38

A

Question 39

99 . Which of these is most likely to lead to a client telling you about their emotional state?
a) You look great! How do you feel?
b) This month is often a hard one , and women sometimes feel like they do in transition: “I can’t do this”. Is that how you feel?
c) Most mothers find this trimester is a time of great excitement and joy, but some women spend a lot of time worrying or even feeling sad about the fact their lives are about to change. How are you doing?
d) How have you been feeling this month?

Answer 39

D

Question 40

100 . The following are all risk factors for which complication of pregnancy? Pelvic inflammatory disease, IUD in situ, history of tubal ligation, in vitro fertilization.
a) Stillbirth
b) Ectopic pregnancy
c) Molar pregnancy
d) Multiple pregnancy

Answer 40

B

Question 41

101 . At 30 weeks, Louris tells you she’s embarrassed to tell you this, but she has dark blue spots on her labia. She doesn’t want an exam, but describes them as looking like small purple grapes, and she says the area feels very swollen and ‘full’. You suspect vulvar varicosities, and, when you describe them to Louris, she agrees. Which of the following is not appropriate advice for her?
a) Try to stimulate your circulation frequently by exercising.
b) You could try taking 600 units of Vitamin E (not with other supplements, but with fatty food), nettle infusion (1-2 cups a day) or freeze dried nettle capsules, or collinsonia root tincture or tablets (up to 6 daily if needed).
c) Try not to stand for prolonged periods of time.
d) Don’t sit with your legs crossed, and use compression stockings.

Answer 41

D

Question 42

102 . You’re telling Mackenzie how to do kick counts. Which of these do you not tell her?
a) If two movements follow straight on the heels of one another, such as baby moving an arm and then immediately a leg, count only 1 movement for this.
b) You should feel 8-10 separate movements in the hour you’re counting for.
c) Count for an hour each day, after your biggest meal of the day.
d) Hiccups count as movements.

Answer 42

D

Question 43

103 . Leilah calls you at 29 weeks to tell you she’s been feeling cramping and pulling in her uterus, and she’s worried it’s pre-term labor. On further questioning, you discover that the sensations are just on the sides of her belly, and does sometimes happen after sudden movement. Which of these is the most accurate explanation of what’s going on and a good suggestion for what Leilah should do?
a) Leilah seems to be feeling the tendons (which contract to help open the cervix) being stretched. One suggestion for helping relieve the pain is wearing a fitted maternity belt to help decrease the pressure on the tendons.
b) Leilah seems to be feeling the round ligaments (which contract to help open the cervix) being stretched. One suggestion for helping relieve the discomfort is avoiding sudden movements.
c) Leilah seems to be feeling the tendons (which help support the uterus) being stretched. One suggestion for helping relieve the pain is sleeping with good support from pillows.
d) Leilah seems to be feeling the round ligaments (which help support the uterus) being stretched. One suggestion for helping relieve the discomfort is pelvic lift exercises.

Answer 43

D

Question 44

104 . Katya is 34 weeks pregnant when she tells you she’s very itchy on her belly, breasts and back. Which of these is not a good recommendation for helping ease this?
a) An oatmeal bath can provide great comfort.
b) Eat liver-healthy foods such as raisins, salty foods and foods with a high saturated fat content.
c) Eat foods high in choline, such as wheat germ and brewer’s yeast.
d) Take a liver tincture with dandelion root and yellow dock.

Answer 44

B

Question 45

105 . Janiya, 20 weeks pregnant, recently moved to the USA and just called to enquire about hiring you as her midwife. What is one concern about her care that you want to address the first time you meet with her, and then revisit periodically?
a) What social support system she has in place.
b) What prenatal care she had before moving to the US.
c) Whether she can afford to pay you.
d) Whether she’s in the country legally.

Answer 45

A

Question 46

106 . You’ve carefully researched and written practice protocols, including those for emergency transfer of care. Today, one of your favorite clients is in a situation that would normally trigger emergency transfer, but she begs you to try a few more things before activating the protocol. What do you do?
a) If you list all the risks and benefits of the decision and your client gives informed consent, you can choose not to follow the protocols on this occasion.
b) If you feel that you can try the extra steps before transfer without putting the client or her baby at significant risk, you should follow her request.
c) Follow your protocol. You used your best clinical judgement to write the protocols without emotion influencing them, and so the safest thing to do for your client is to follow them now.
d) Follow your protocol. You would get a bad reputation if you displayed favoritism to one client.

Answer 46

C

Question 47

107 . Marge is 41w5d, and is now seeing you daily for prenatal appointments so that you can carefully monitor the health of the fetus. You’ve been palpating her abdomen and notice an apparent decrease in amniotic fluid volume. What should you do?
a) Oligohydramnios is physiological in post-date pregnancies, as fetal urinary output naturally drops as the fetus matures. You should continue expectant management, waiting for labor to start naturally.
b) Oligohydramnios is a sign that fetal urinary output has dropped, which indicates a problem with the kidneys. You should refer the neonate to a pediatrician within 24 hours of birth.
c) Oligohydramnios can lead to cord compression and fetal compromise. You should refer Marge for an ultrasound to confirm your suspicion, and transfer care to a hospital if it is correct.
d) Oligohydramnios increases the risk of prolapsed cord, especially if the fetus is not well-engaged at the time of ROM. You should arrange to attend immediately after ROM to check on fetal health.

Answer 47

C

Question 48

108 . Which of the following is not a sign of a fetus in an occiput posterior position?
a) Extreme symphysis pubis pain is felt during labor.
b) More fetal movement is palpated anteriorly, both left and right laterally.
c) A concave shape is seen around the umbilicus.
d) Fetal spine is difficult or impossible to palpate.

Answer 48

A

Question 49

109 . Urine dipsticks show positive for blood in all of these situations bar which?
a) Sometimes present in small quantities in healthy urine.
b) Conditions outside the urinary tract such as severe burns or injuries, ingestion of aspirin or hemolytic anemia.
c) Lower urinary tract trauma or infection has caused bleeding.
d) Contamination from vaginal discharge containing blood.

Answer 49

B

Question 50

110 . At 34 weeks, La-Keysha tells you she’s had several leg cramps in the last week or so, and some have been very painful. Which is not a good response?
a) If you think leg cramps hurt, just you wait until labor! One thing you can do is get new shoes that support your feet more than those ones do.
b) Leg cramps can be very painful. When you do get one, flex your foot like this, instead of pointing it out.
c) Leg cramps are often caused by electrolyte imbalances or low calcium and other minerals. Try taking 350 mg of magnesium before bed and drinking nettle leaf infusion.
d) Leg cramps are certainly no fun, but they’re very common and nothing to worry about. Make sure you’re drinking enough water and eating foods high in calcium, magnesium and potassium.

Answer 50

A

Question 51

111 . Larissa is 34 weeks pregnant and her fetus is breech, confirmed by ultrasound. You explain various positions and exercises that she can try to help encourage a breech to turn. These include using a tilt board, forward leaning inversions, handstands in the pool, and knees and chest. What is the rationale for all of these exercises?
a) These exercises help move the fetus from transverse to oblique and then to cephalic.
b) These exercises cause the anterior uterus to hang like a hammock, thereby encouraging the fetus to roll from posterior to anterior.
c) These exercises cause the heavy fetal head to be pulled by gravity, moving the fetus into a cephalic position.
d) These exercises all create more room in the lower uterus. When getting back to upright, the fetus can then use this space and the pull of gravity to get into a better position.

Answer 51

D

Question 52

112 . Which of these includes an item that is not a symptom of a rectocele?
a) Dyspareunia or a sense of fullness in the vagina.
b) The urge to have multiple bowel movements each day.
c) Fecal incontinence or diarrhea
d) Constipation or the need to press against the vagina or perineum to have a bowel movement

Answer 52

C

Question 53

113 . Which of the following is not a physiologic body change during pregnancy?
a) Increase in the number of infections because the immune system is suppressed.
b) Nails may become softer and more brittle, splitting more easily, but they also normally grow faster.
c) Areolas, freckles, moles and the linea negra may all darken and enlarge during pregnancy.
d) Relaxin loosens joints and ligaments (leading to ‘pregnancy waddle’, lordosis etc.)

Answer 53

A

Question 54

114 . At their 32-week appointment, Laron tells you their lower back is causing a lot of discomfort, and they’re not sure how to get through the rest of pregnancy, since it will surely get worse. You suspect the baby is in a posterior position, and palpate Laron’s abdomen; the fetus is actually LSA, so Laron does not have the baby’s head pushing on their sacrum. Laron has marked lordosis. Which suggestion is not appropriate for Laron?
a) When lifting, put your feet apart, one slightly in front, and stoop and use your legs to take the weight, not your back.
b) Regular exercise like yoga, swimming and pelvic tilts may help, and avoid standing still for too long.
c) You should wear a tight belly band to help take the weight of the baby off your lower back.
d) Heating pads and warm baths or an ice pack wrapped in a towel could both help.

Answer 54

C

Question 55

115 . Which of the following would not be part of appropriate emergency treatment for a uterine rupture?
a) Attempt to push the fetus back into the uterus.
b) Administer oxygen.
c) Start an IV with lactated Ringer’s or normal saline.
d) Call 911 and request an ambulance. Call the hospital and tell them you suspect uterine rupture and tell them the client’s blood type.

Answer 55

A

Question 56

116 . Maddy calls you at 38.4 weeks to tell you she “woke up in a puddle” and isn’t sure if she had urinary incontinence or if her membranes ruptured. Which of these statements about identification of rupture of membranes is not accurate?
a) An abdominal ultrasound can confirm low levels of amniotic fluid, but cannot reliably confirm rupture of membranes.
b) Nitrazine paper may give a false positive with presence of a vaginal infection (such as BV), of semen, or of soap.
c) A blood test for fetal fibronectin (fFN) to diagnose PROM has both high sensitivity and specificity.
d) The fern test may produce false positives if there is contamination with blood, semen or cervical mucous.

Answer 56

C

Question 57

117 . Which of these are not all symptoms or signs of a uterine rupture?
a) Sudden loss of fetal station, vaginal bleeding
b) Abrupt bradycardia/recurrent decelerations that become deeper, easily palpable fetus
c) Maternal anxiety, abdominal pain/uterine guarding
d) Uterine tachysystole

Answer 57

D

Question 58

118 . Which of the following is not a synonym of the others?
a) Bladder prolapse
b) Cystocele
c) Anterior prolapse
d) Rectocele

Answer 58

D

Question 59

119 . Kelly’s urine stick test is positive for ketones. Which is not a reasonable explanation for this?
a) Kelly has gestational diabetes. In this case, glucosuria will also be seen
b) Kelly is malnourished, so her body is breaking down fats and protein for energy
c) Kelly is in labor. In this case, significant glucosuria and alkaline urinary pH are also likely to be seen
d) Kelly did not produce a ‘clean catch’ urine sample

Answer 59

D

Question 60

120 . Kate’s urine specific gravity is 1.02. What does this mean?
a) Normal values are between 1.015 and 1.05. 1.02 is on the lower side of this range, indicating that Kate is probably dehydrated.
b) The specific gravity of water is 1.0, so urine is always at least that high. 1.02 is on the higher side of normal, indicating that Kate is probably a little dehydrated (or has had diarrhea or vomiting).
c) Normal specific gravity values of urine are between 0.8 and 1.2. Since 1.02 is in the middle of that range, her hydration is perfect.
d) Normal specific gravity values are 1 to 10. 1.02 is right at the lower boundary of normal, indicating that Kate is probably drinking a lot of water. Discuss hydration with her to ensure she’s not drinking too much.

Answer 60

B

Question 61

121 . At his wife’s appointment, Jason tells you he’s very concerned because they’ve just found out that his wife is A-, and he knows the baby’s blood crosses the placenta and so will mix with hers and could cause isoimmunization, which might make their baby very ill. What do you tell him?
a) The placenta is designed such that the baby’s and mother’s blood do not mix. Occasionally, some of baby’s blood does get into the mother’s bloodstream, such as if they’re in an accident or at birth, but there’s RhoGAM for that if they want it, and it’s unlikely that the current pregnancy would be affected even if there was blood transfer.
b) The baby has a tiny blood volume, and so very little fetal blood gets into the maternal bloodstream unless there’s something like an accident or during birth. At these times, RhoGAM is recommended to reduce the risk of isoimmunization, but they could have RhoGAM earlier in pregnancy if they’re concerned.
c) Although fetal blood and maternal blood do mix at the boundary of the placenta, there’s a very good filtration system there, and so Rhesus antibodies don’t usually get into the maternal bloodstream. If they do, they have 72 hours to get RhoGAM, if they want it, which effectively prevents isoimmunization.
d) Although fetal blood and maternal blood do mix at the boundary of the placenta, there’s a very good filtration system there, and so Rhesus antigens don’t usually get into the maternal bloodstream. If they do, they have 72 hours to get RhoGAM, if they want it, which effectively prevents isoimmunization.

Answer 61

A

Question 62

122 . Landry tells you she’s been feeling a lot of tingling and numbness in her thumb, index finger and middle finger. You ask her to bend her wrists and put her hands together, back-to-back. Within 30 seconds, she tells you she feels the tingling and numbness and also discomfort. Which of these is not a good recommendation for Landry?
a) Drink skullcap and take a B-complex supplement
b) Wear a wrist splint at night to place the wrist in a neutral position
c) When doing nerve gliding exercises, apply crushed ice to the hand for 20 minutes prior to the exercise, and apply heat to the hand afterwards.
d) Hand and wrist exercises, like fist to stop sign, fist to fan, thumb touches and gentle wrist stretches.

Answer 62

C

Question 63

123 . At her intake appointment at 11 weeks, Keona tells you she’s worried because she’s been feeling exhausted, even though the baby is tiny still. Which of these would you not say to her?
a) Just wait until you have a 2 year old! You’ve no idea!
b) Fatigue can be a sign of anemia, but the blood test we’re doing will tell us if that’s the case for you, and it’s an easy thing to solve if it is.
c) Fatigue is normal in the first trimester and usually disappears by the second trimester, so you’re nearing the light at the end of the tunnel!
d) Eating a healthy diet, and alternating resting with exercise can all help mitigate fatigue.

Answer 63

A

Question 64

124 . Marge (G5P4004) joins your practice at 16 weeks. When you’re calculating her due date, she tells you that her menstrual cycles are regular at 28 days, that she only had intercourse on cycle days 13 and 20, and got a very faint positive pregnancy test on day 24. Her previous pregnancies had somewhat similar scenarios, and GA at the times of birth were 41w6d, 41w5d, 42w3d, 42w1d. You live in a state where midwives can only legally deliver babies until 42w0d. What should you do?
a) Counsel Marge that, whilst you’re happy to care for her during pregnancy, there’s a significant chance that her pregnancy will go to post term, at which stage you’d need to transfer her care. You could still attend the birth, but in the role of a doula, not a midwife.
b) You expect that Marge will go to post term, but safely so, as all her other pregnancies resulted in healthy babies. Since your state’s laws are not flexible on this, you should record her GA as 2 weeks behind its true value throughout pregnancy.
c) Marge is likely to go to post term if there is no significant change to this pregnancy, and she’s desperate to have an our of hospital birth with a midwife, so you suggest to her the idea of smoking during pregnancy.
d) Since it’s likely that Marge will go post term without assistance, you recommend starting herbs, castor oil, a membrane sweep and AROM at 40w.

Answer 64

A

Question 65

125 . At 28 weeks, Lydia complained of varicose veins, and you told her of various ways she could help mitigate them. Lydia chose to exercise more, has been trying to avoid standing for prolonged periods of time, and has been taking Vitamin E. She decided not to use compression socks because it was too hot. Today, you want to go through signs and symptoms of thrombophlebitis with her. Which of these will you not tell her to look out for?
a) Swelling across your body, pain if you touch one area of the calf, tenderness along the length of the vein.
b) Heat, pain, swelling and/or a knot or cord you can feel (but don’t massage it or poke it too much!)
c) Flex your foot (lift towards your leg) to see if there’s sharp pain in the leg. (Think of embolization.)
d) Fever, racing heart, severe pain in the leg that starts suddenly.

Answer 65

C

Question 66

126 . Mary, G2P1001, is a VBAC client who was given a cesarean for ‘failure to progress’. The obstetrician told her she’d been 4 cm for 3 hours because her baby was too big for her pelvis. Mary desperately wants a different outcome this time, but is very nervous about whether it will be successful. Which of these would you not tell her?
a) Although your pelvis hasn’t changed size or shape, there’s a chance this baby will be small enough to fit through. If you restrict calories from 36 weeks, you will improve your chances of a successful VBAC.
b) It would be good to join a group like the International Cesarean Awareness Network, as they are very supportive and you’ll hear a lot of success stories, helping you believe in yourself.
c) With a midwife, you’ll be doing lots to help get through that early labor stage, from how to face the pain to eating, hydrating and moving around, or resting if that’s the better option.
d) In early labor, it’s very common for progress to be slower. As long as you and your baby are handling labor well, we won’t rush you through this. Your body isn’t ‘broken’.

Answer 66

A

Question 67

127 . You’re practicing in a state where midwives can attend births from 37.0 weeks. Moira (G1P0000) calls you at 36.5 weeks to tell you she’s had menstrual-like cramps on and off for a couple of hours, and had diarrhea earlier today. You suspect she may be in early labor. What should you do?
a) Suggest that Moira take a Benadryl and some calcium and then try to sleep.
b) Suggest that Moira drink some cayenne tea and then go for a walk for an hour or so.
c) Since this is Moira’s first labor, it’s likely it will take a long time, so you decide to let it take its course. At worst, the baby will be born at 36.6, and no-one will care about you attending a birth 1 day early!
d) Suggest that Moira drink plenty of water, take a warm bath with lavender oil and epsom salts, and then lie down on her left side.

Answer 67

D

Question 68

128 . At her 16-week appointment, Liz complains of a slightly itchy vagina and a fishy smell after intercourse. On inspection, you see a grey, adherent discharge coating the vaginal walls, a pH of 4.5, and also note the fishy odor, and so you diagnose bacterial vaginosis. Liz does not want to take antibiotics, so you recommend various non-allopathic therapies, including echinacea tincture, bayberry bark infusion, probiotics and use of a tampon soaked in acidophilus culture. At 18 weeks, Liz contacts you to report no change in symptoms. She’s now tried every non-allopathic treatment she can find, but is reluctant to take antibiotics during pregnancy, and asks what the risks to the baby are of doing nothing. Which of these is not correct?
a) Preterm birth
b) Pelvic inflammatory disease
c) Spontaneous abortion
d) Chorioamnionitis

Answer 68

B

Question 69

129 . At 36 weeks, you ask Jess to describe her breasts, and she says her nipples are like dimples. You ask if you can take a look and see inverted nipples. What do you do?
a) Tell Jess that inverted nipples make breastfeeding far harder, but she might still be able to get it to work if she works hard. Talk to her about several things she could try, and tell her to buy in supplies including a pump, various bottles and nipple cream.
b) Inverted nipples are the norm. Tell Jo everything looks perfect and you’re sure she’ll have a long and enjoyable breastfeeding journey.
c) Tell Jess that this is fairly common. Whilst it does make breastfeeding more challenging, there are many things that can be done to help make it possible. Talk through a couple and suggest supplies she should have for after the baby is born, including a breast pump and at least 1 kind of nipple shield.
d) Tell Jess to start power-pumping as soon as the appointment is over and to do at least 4 hours a day of pumping, as this can help suck the nipples out, solving the problem.

Answer 69

C

Question 70

130 . You’re called in as assistant to a birth with a woman you don’t know, and arrive before the primary midwife. Contractions suddenly stop and the client’s pulse begins to rise. She’s looking pale and says she feels faint. When you listen to FHT, there’s been a significant drop in rate. What do you suspect?
a) Uterine rupture
b) She’s experiencing a lull in contractions before second stage
c) Ketoacidosis
d) Maternal anxiety

Answer 70

A

Question 71

131 . Which of the following has inaccurate information on possible methods for stimulating the start of labor in a post-dates client (with intact membranes)?
a) Having the client take: Castrol oil, blue/black cohosh, red raspberry leaf, evening primrose oil (orally or internally), cimicifuga, and/or caulophyllum.
b) Chiropractic adjustment or acupuncture.
c) Stripping membranes (using sterile technique), amniotomy (with a fetus that is well-engaged) or attempting to reposition a malpositioned fetus.
d) Sexual intercourse (unprotected), nipple stimulation, and discussing emotional blockages that may be interfering.

Answer 71

A

Question 72

132 . At her intake appointment, Mal asks you in what situations you would transport to hospital during labor or after the birth. Which of these is not one of the things you’d tell her?
a) You’d transport if her baby was struggling to transition after birth and needed more support than you could give.
b) You’d transport if there was a postpartum hemorrhage that you couldn’t stop or if total blood loss was high even though you had stopped it.
c) You would only transport during labor if there was a true emergency.
d) You’d transport if the cord came out of the cervix before the baby, because then her baby would be at significant risk of not getting enough oxygen, because the cord would be squeezed by the baby’s head.

Answer 72

C

Question 73

133 . Which of the following best describes what information an ultrasound ordered for a post-date client can give you?
a) Amniotic fluid volume; if this is low, there is an increased risk of fetal compromise. This value should be >5 cm and <16 cm.
b) Estimated fetal weight, amniotic fluid index, fetal gender, whether placenta is clear of the cervix, number of fetuses present, number of chambers of the heart, number of vessels in the cord.
c) The ultrasound gives you exactly the same information as a biophysical profile, with the added benefit of estimated fetal measurements (e.g. the dimensions of the head), which can help predict problems such as CPD and shoulder dystocia.
d) AFI, fetal tone during the ultrasound, presence or absence of fetal breathing movements during the ultrasound, FHR (including variability and reactiveness) during the ultrasound, grade of the placenta, estimated fetal weight (large margins of error).

Answer 73

D

Question 74

134 . Which of these best describes an ectopic pregnancy?
a) An embryo that implants outside the uterus, i.e. in the fallopian tubes or in the abdominal cavity.
b) An embryo that is fertilized inside a fallopian tube.
c) An embryo that implants inside a fallopian tube.
d) A pregnancy implanted outside the endometrial cavity, i.e. in fallopian tubes, cervix, ovaries or abdominal cavity.

Answer 74

D

Question 75

135 . Lindy’s fundal height measurements for the last few appointments have been: 20 weeks: 20 cm, 24 weeks: 25 cm, 28 weeks: 30 cm, 30 weeks: 33 cm. When you measure her today, at 32 weeks and 4 days, fundal height is 36 cm. Which of these is not a likely explanation for the high fundal height measurements?
a) Gestational diabetes
b) Polyhydramnios
c) Multiples
d) Incorrect dates

Answer 75

D