6. Postpartum (241-285)

Question 1

241 . Which of the following statements about breastfeeding/chestfeeding is most accurate?
a) Contaminants from environmental exposure, such as pesticides in food or chemicals from cleaning products never enter the breastmilk, but these chemicals are present in formula, and so breastfeeding/chestfeeding is the safest option.
b) Contaminants from environmental exposure, such as pesticides in food or chemicals from cleaning products can enter the breastmilk, but breastfeeding/chestfeeding is still thought to improve a child’s cognitive scores as compared to formula feeding in the vast majority of cases.
c) Contaminants from environmental exposure, such as pesticides in food or chemicals from cleaning products can enter the breastmilk, and hence formula feeding is best for anyone not eating an organic plant-based diet or who is using harsh chemicals for cleaning.
d) Contaminants from environmental exposure, such as pesticides in food or chemicals from cleaning products do not enter the breastmilk, but they are not present in formula either, and so both are equally safe. Only breastmilk contains antibodies, however.

Answer 1

B

Question 2

242 . Which of the following would you not normally evaluate at a 3-4 day postpartum appointment?
a) Edinburgh Postnatal Depression Scale (should be <10)
b) The lochia for color, amount and odor (should be serosa, lighter flow)
c) The uterus for normal inversion (should be around 3-4 cm below umbilicus)
d) Breasts for engorgement or signs of clogged ducts, and nipples for signs of cracking

Answer 2

A

Question 3

243 . Which of the following contains only items that would normally help treat sore nipples?
a) Assess for tongue tie (refer if present) or chomping down (discontinue bottle/pacifier), and ensure the same nursing position is used at every feed.
b) If lips are not flanged open when breastfeeding, manually correct this. If latch is not good, pull the nursing baby off the breast and correct this.
c) Stopping nursing on one side after the baby has stopped visibly/audibly swallowing, and leave that side exposed to the air at least whilst feeding on the other side.
d) Apply topical agents which can be left on the nipple for subsequent feeds, such as honey, or apply expressed breastmilk.

Answer 3

C

Question 4

244 . Petra just gave birth to a 9lb 8oz occiput posterior baby, after around 2 hours of pushing. There was a shoulder dystocia, and you had to work quite hard to resolve it, using suprapubic pressure and eventually adducting the anterior shoulder and sweeping that arm out, at which point the baby delivered. Understandably, Petra was in a lot of discomfort afterwards. She did not want to get up to empty her bladder, and asked you to catheterize her. Today is her 1-day postpartum appointment, and she tells you she has unrelenting pain in the anterior pelvis and suprapubic region, radiating out to her hip joints and down her legs. She says she’s still not got up to use the restroom, and she cannot even lift her legs because of the pain. What diagnosis do you suspect?
a) Symphysis pubis diastasis
b) Sciatica
c) Fractured pelvis
d) Hematoma

Answer 4

A

Question 5

245 . You’re performing a Pap test at Paula’s 6-week postpartum appointment. Which of the following statements is most accurate?
a) A medium-sized speculum is normally appropriate. The cervix will likely be situated high in the vaginal vault, will likely feel soft, and the external os will probably take of the form of a dimple.
b) A small speculum is normally appropriate. The cervix will likely be situated low in the vaginal vault, will likely feel soft, and the external os will probably take of the form of a dimple.
c) A small speculum is normally appropriate. The cervix will likely be situated low in the vaginal vault, will likely feel firm, and the external os will probably take of the form of a slit rather than a dimple.
d) A medium-sized speculum is normally appropriate. The cervix will likely be situated high in the vaginal vault, will likely feel firm, and the external os will probably take of the form of a slit rather than a dimple.

Answer 5

D

Question 6

246 . Which of the following midwifery management choices would not be appropriate for a mild infection of a vaginal tear?
a) Keep area dry, cool and clean
b) Debriding tissue
c) Administer broad spectrum antibiotics
d) Consult a physician

Answer 6

B

Question 7

247 . What findings should you have on palpation of the uterus a few hours after birth?
a) Firm, fundus approximately at the umbilicus.
b) Boggy, fundus approximately at the umbilicus.
c) Intermittently firm and soft, fundus 2-4cm above the umbilicus.
d) Firm, fundus 2-4cm above the umbilicus.

Answer 7

A

Question 8

248 . You’re teaching your client how to contract and release the ischiocavernosus and transverse perineal muscles, elevator and diaphragm muscles and the pubococcyygeal muscle, separately and in unison. Why?
a) These exercises stretch the muscles of the pelvic floor and birth canal.
b) These exercises strengthen the muscles of the birth canal.
c) These exercises strengthen the muscles of the pelvic floor and birth canal.
d) These exercises stretch the muscles of the pelvic floor.

Answer 8

C

Question 9

249 . Which of the following is not a cause for concern in a penis healing after circumcision?
a) Pustular drainage
b) No voiding for the first 24 hours
c) Swelling increasing after the first 24 hours
d) Edema of the remaining foreskin within 24 hours, with scant serosanguinous drainage

Answer 9

D

Question 10

250 . You’ve just helped your client birth her baby, but noted obvious jaundice from head to knees in the newborn exam. Which of these is not appropriate management?
a) Draw cord blood in both red- and purple-topped tubes for baseline bilirubin levels
b) Tell your client to breastfeed as often as possible after you’ve left, ideally 8-10 times a day, and to call you if the jaundice spreads to hands and feet.
c) Initiate immediate transfer
d) Explain possible treatments, including phototherapy and the possibility of the need for an exchange transfusion

Answer 10

B

Question 11

251 . What height should the fundus be 2 weeks postpartum?
a) Not palpable
b) Approximately 5-6cm above the symphysis pubis
c) Half way between the symphysis pubis and the umbilicus
d) You should not be measuring fundal height postpartum, as this can increase bleeding

Answer 11

A

Question 12

252 . Which of the following is not a common sign/symptom of infection of a vaginal tear?
a) Localized pain and edema
b) Wound separations or purulent exudate
c) Red and inflamed wound edges
d) Temperature of over 103 F

Answer 12

D

Question 13

253 . When a baby is latching, which of the following is not ideal?
a) Ensure a large part of the areola is in the mouth, with more areola showing above the mouth than below
b) Ensure the nipple can be seen sliding slightly in and out of the newborn’s mouth when sucking
c) Wait for a wide gape before latching
d) Ensure lips are flared

Answer 13

B

Question 14

254 . Which of the following is not in the differential diagnosis for postpartum UTI?
a) Cholecystitis
b) Pancreatitis
c) Appendicitis
d) Placental abruption

Answer 14

D

Question 15

255 . Which of the following is an accurate description for breast milk jaundice?
a) A common type of jaundice that affects approximately 70% of exclusively breast-fed babies (and approximately 50% of formula-fed babies). Self-limiting, but phototherapy speeds up resolution.
b) A type of jaundice that occurs when a baby is exclusively formula-fed, and is therefore lacking the proteins found in breast milk that normally help with breaking down bilirubin.
c) A type of jaundice that develops in newborns who are struggling with breastfeeding and aren’t getting enough breast milk.
d) A type of jaundice associated with breast-feeding, typically occurring 1 week after birth. Rarely causes complications.

Answer 15

D

Question 16

256 . Which of the following is not a sign/symptom of uterine infection?
a) General malaise
b) Pelvic pain
c) Malodorous lochia
d) Uterine superinvolution

Answer 16

D

Question 17

257 . Philippa is showing signs of having postpartum blues. Which of the following is not good advice for her?
a) Reassure Philippa that this is common and usually resolves by 1-2 weeks postpartum.
b) Refer Philippa to a psychotherapist for counselling.
c) Encourage seeking and accepting support from family and friends.
d) Ensure Philippa has lots of contact with others, in person or virtually, including friends, family and other new parents.

Answer 17

B

Question 18

258 . 36 hours postpartum, Olivia (G4P4004) complains of terrible after pains. Which of the following is not a good relief measure for them?
a) Breastfeeding
b) Ibuprofen (preferable) or acetaminophen.
c) Strong ginger tea, motherwort or hellonias virburnum
d) Emptying the bladder frequently, and then lying prone with a pillow under her lower abdomen.

Answer 18

A

Question 19

259 . You’re giving Phoebe information and advice about symptoms of mastitis, including unilateral pain and redness, a fever above 101F, malaise, fatigue and flu-like symptoms, and give advice on treating clogged ducts and mastitis. Which of the following do you not recommend to her?
a) Warm compresses on the breast before feeds can be very beneficial, including warm salt water or fenugreek tea. Cold cabbage leaves after feeds can decrease inflammation and engorgement.
b) Aim to fully empty breasts at each feeding, ensuring a good latch, and gently massage or squeeze the breast while the baby is nursing. Hand express or pump after feeds if necessary.
c) Take advice from others, including breastfeeding support groups and IBCLCs, with caution. Midwives are experts at breastfeeding, and so they should be the first (and, ideally, only) person you go to for advice about all things breastfeeding, including mastitis. Antibiotics are rarely, if ever, indicated with mastitis.
d) Massage can help, but it’s not comfortable! Put coconut or olive oil on your breast, and then use your fingers to knead in circles over painful areas, gradually moving towards the nipple, or use a wide-toothed comb to comb over the plugged area down to the nipple.

Answer 19

C

Question 20

260 . Your client had her baby circumcised shortly after birth, and you’re running through how to care for his penis with her. Which of these is not a recommendation you give?
a) Use vaseline or a healing salve after diaper changes
b) Once the penis is healed, clean the smegma off the tip at diaper changes
c) Clean the penis gently with alcohol after diaper changes
d) Change the diaper frequently, but leave the original gauze on for 24 hours, unless otherwise directed by the provider who did the surgery

Answer 20

C

Question 21

261 . Which of the following is most likely to worsen diastasis recti?
a) Not exercising during pregnancy
b) Core stability strengthening
c) Surgery
d) Belly binding

Answer 21

A

Question 22

262 . Which of the following timings for return of menses is abnormal?
a) Return of menses at 6 weeks for a breastfeeding/pumping client.
b) Return of menses at 5 months for a non-breastfeeding/pumping client.
c) Return of menses at 9 months for a breastfeeding/pumping client.
d) Return of menses at 6 weeks for a non-breastfeeding/pumping client.

Answer 22

B

Question 23

263 . What is the most appropriate management for puerperal infection of the uterus?
a) Since many different organisms could be responsible (strep, staph, E. coli, and many others), culturing is advisable in order to identify which antibiotic to prescribe.
b) Since GBS is by far the most common cause, treatment with Penicillin G is the best option, unless the client has a known allergy to this.
c) It is difficult to know which antiviral is most appropriate for any given infection, but oseltamivir phosphate and zanamivir are generally good choices. If these do not help, peramivir can be given instead.
d) Antifungal creams and pessaries such as clotrimazole are most appropriate in the breastfeeding client. Oral fluconazole can also be prescribed, as only small amounts transfer to breastmilk.

Answer 23

A

Question 24

264 . Which of the following outlines the appropriate management for DVT?
a) The client should take NSAIDs such as ibuprofen or aspirin and wear support stockings, but should also be told to watch out for the signs and symptoms of a pulmonary embolism, and to go to the nearest emergency room should any develop.
b) The client should apply a warm compress to the affected area and elevate it. Support stockings should be encouraged.
c) The client should be referred to their PCP during business hours. Treatment involves medications to thin the blood, such as heparin or warfarin.
d) The client should go to the nearest emergency room. Treatment involves preventing growth of the clot, preventing pulmonary embolism and reducing the risk of additional clots in the future.

Answer 24

D

Question 25

265 . Which of the following is not a good step when preparing to breastfeed/chestfeed a baby?
a) Ensure the parent is comfortable and has easy access to water
b) Position baby’s belly towards parent
c) Ensure the head is turned slightly left or right of midline, depending upon nursing position and side.
d) The baby should be positioned so the nipple is just below the nose

Answer 25

C

Question 26

266 . You’re performing a bimanual exam on Paula 6 weeks postpartum, and palpate a pear-shaped organ in the midline and anterior. What observation is abnormal for this organ?
a) Immovable
b) Firm
c) Smooth
d) Non-tender

Answer 26

A

Question 27

267 . Which of the following is not a sign/symptom of a puerperal UTI?
a) Urinary urgency
b) Dysuria
c) Oliguria
d) Lower abdominal pain

Answer 27

C

Question 28

268 . Which of the following is not in the differential diagnostic for pathological jaundice?
a) Icterus
b) Meconium staining
c) Yellow tint to normal skin, e.g. neonate of Hispanic, Mediterranean or Asian origin
d) Physiologic jaundice

Answer 28

A

Question 29

269 . Your client has been breastfeeding for a week when she calls to say that she’s having stabbing pains behind the areola when nursing, and her nipple feels like it’s burning and itches. When you go to see her, you note flaking skin on the nipple, and patches of shiny skin around that on the areola. Which of the following is not an appropriate part of the management?
a) Use antifungal medications such a miconazole or clotrimazole, or corticosteroid cream.
b) Taking probiotics, limiting or eliminating dietary sugar, and washing with grapefruit seed extract rinse or dilute apple cider vinegar after a feed.
c) Ensure nipples stay warm and damp between feeds. One method is to express a little milk into a breastpad, and to wear this until the subsequent feed.
d) Use gentian violet on nipples/areolas and the baby’s mouth, or use acidophilus solution or coconut oil. Wash all clothes with high heat.

Answer 29

C

Question 30

270 . Baby Penda was born late last night and you’re visiting her and her mother, Mariama, today. You’ve been there for 40 minutes, chatting about the birth and how they’re both doing, and Penda has been sleeping peacefully throughout. Mariama is exclusively breastfeeding, and says that, other than having to repeatedly try to stimulate Penda to get her to nurse, there haven’t been any problems with it. Mariama is from Senegal and Penda’s father is an American of Italian descent, and Penda has a beautiful olive-brown skin. When you eventually hold her, you touch her nose and see her father’s greenish-yellow Italian coloring coming through. After 10 glorious minutes of holding the sleeping baby, you finish up your appointment and arrange to see them again in 2 days’ time, unless they want you to visit sooner. Before that appointment, Mariama ends up in the ER with Penda in critical condition. Which diagnosis did you probably miss?
a) Persistent hypertension of the newborn
b) Sleepy baby syndrome
c) Neonatal diabetes
d) Pathological jaundice

Answer 30

D

Question 31

271 . Which of the following statements about breastfeeding/chestfeeding is not accurate?
a) Genetics, endocrinology and epigenetics all effect breastmilk production and feeding.
b) If the parent has the flu or another infection, breastmilk helps protect the infant. It might be preferable to limit exposure in person, however, and so pumped milk given by another care provider may be appropriate.
c) If the parents has diabetes mellitus, breastfeeding/chestfeeding can help reduce the risk of the baby developing diabetes. Insulin can still be used as needed.
d) If the parent is HIV positive, they can be reassured that breastfeeding/chestfeeding is perfectly safe, as the virus is not passed through breastmilk.

Answer 31

D

Question 32

272 . Which of the following would be a variation of normal lochia?
a) A foul smell to the lochia.
b) 1050ml blood loss within the first 24 hours of birth.
c) No decrease in bleeding by 5 days postpartum.
d) An increase in bleeding at 7-14 days postpartum due to secondary sloughing of placental eschar.

Answer 32

D

Question 33

273 . When collecting a subjective postpartum history from a client, which of the following is not an important consideration?
a) Listen for any red flags, and follow up on them.
b) Ensure you use the correct sized blood pressure cuff.
c) Ask both open- and closed-questions.
d) Respond in non-judgmental ways to answers given.

Answer 33

B

Question 34

274 . What is the approximate expected rate of involution over the first 10 days postpartum, as measured by fundal height?
a) 1cm further below the umbilicus per day
b) No change for the first 4-5 days, then 1-2cm decrease in height each day
c) Between a 1cm increase and a 2cm decrease in fundal height each day, with a gradual decrease on average.
d) 2cm further below the umbilicus per day

Answer 34

A

Question 35

275 . Which of the following statements about postpartum psychosis is incorrect?
a) The average duration of postpartum psychosis is 40 days, but it recurs in 50-75% of cases.
b) Can start as early as 2-3 days postpartum or as late as 1 year postpartum, but usually starts within 2-4 weeks of birth.
c) This is the most severe form of postpartum depression, and usually results after a gradual worsening of PPD signs and symptoms.
d) This is a life-threatening emergency and requires immediate psychiatric evaluation and treatment.

Answer 35

C

Question 36

276 . You’re at Pippa’s 4-day postpartum appointment, and she tells you she recently started feeling very overwhelmed, tearful and restless. She says she’s not been sleeping well and feels frustrated about her constant responsibility for the baby, but that she’s continued loving and caring for him, and breastfeeding is going well other than her nipples are still quite tender. What is the most likely diagnosis?
a) Postpartum blues
b) Postpartum insomnia
c) Postpartum depression
d) Postpartum psychosis

Answer 36

A

Question 37

277 . A neonate you’ve been caring for had signs of jaundice at your last visit, 2 days ago. At that stage, you judged bilirubin levels to be around 9 mg/dl, as the jaundice covered the head down to the level of the bottom of the rib cage. You’d given instructions to help reduce jaundice, and to call you if symptoms worsened. Today, the neonate has tachypnea, a high-pitched cry, poor tone, and the mother reports two instances of emesis. What action do you take?
a) Initiate immediate emergency transfer. The neonate is showing signs of kernicterus.
b) Initiate immediate emergency transfer. The neonate is showing signs of worsening hypobilirubinemia.
c) Refer to the pediatrician. The neonate is showing signs of worsening hyperbilirubinemia.
d) Refer to the pediatrician. The neonate is showing signs of kernicterus.

Answer 37

A

Question 38

278 . Which of the following is not in the differential diagnosis for superficial thrombophlebitis?
a) Hematoma
b) Cellulitis
c) Amniotic fluid embolism
d) Varicosities

Answer 38

C

Question 39

279 . Which of the following is not in the differential diagnosis for postpartum preeclampsia?
a) Gestational preeclampsia
b) Hepatitis
c) Migraine
d) Viral gastroenteritis

Answer 39

A

Question 40

280 . Sammy was born 4 days ago, and blood results following your diagnosis of physiological jaundice are back; bilirubin is 8 mg/dl, which matched with your assessment that jaundice stopped at the nipple line. Which of the following is most likely to reduce the jaundice?
a) After breastfeeding, give Sammy around 0.5-1 oz of water.
b) Reduce breastfeeding to 3 or 4 times a day, and give formula for every other feed.
c) Formula feeding approximately every 3 hours.
d) Exclusively breastfeeding, 10-12 times a day.

Answer 40

D

Question 41

281 . At 3 weeks postpartum, Pam contacts you to say that she’s feeling down. She tells you she expected this time to be a happy, love-filled time of baby cuddles and naps, but instead she isn’t sleeping and feels she’s not a good mother. She denies any thoughts of self harm or of harming her baby, and says she is eating relatively well but her appetite isn’t always great. Pam admits that she sometimes looks at her crying baby but can’t find the energy to go through all the motions of finding out what exactly is making him cry and so she just holds and rocks him. What is the most likely diagnosis?
a) Postpartum blues
b) Postpartum depression (currently mild or moderate)
c) Postpartum psychosis
d) Postpartum depression (currently severe)

Answer 41

B

Question 42

282 . Olivia is Rh negative and has decided she wants RhoGAM postpartum only if the baby is Rh positive. You took a cord blood sample, but have not yet had results back on blood type. By how many hours postpartum should Olivia have the RhoGAM to attempt to avoid isoimmunization?
a) 24 hours
b) 1 hour
c) 72 hours
d) 120 hours

Answer 42

C

Question 43

283 . Which is the appropriate management for a client with postpartum preeclampsia?
a) Refer the client to a physician, expecting IV magnesium sulfate and antihypertensive medication to be prescribed.
b) Like gestational preeclampsia, which spontaneously resolves after birth, postpartum preeclampsia resolves upon cessation of breastfeeding; tell the client to stop immediately.
c) Refer the client to a physician, expecting a full hysterectomy might be needed.
d) Like gestational preeclampsia, which spontaneously resolves after birth, postpartum preeclampsia resolves once hormones are balanced. Advise client starts taking a hormonal BCP immediately.

Answer 43

A

Question 44

284 . How long will it usually take for a circumcised penis to heal?
a) 7-10 days
b) Approximately a month
c) 2-3 weeks
d) 3-5 days

Answer 44

A

Question 45

285 . You’re giving your client advice on family planning. Which of the following is inaccurate?
a) There are many chemical contraceptive options, some of which are hormonal and some not. Before using any of these methods, ask the provider about the effect on breastfeeding/chestfeeding, and the long-term effect on fertility. Several methods affect fertility for a prolonged period of time after discontinuation.
b) There are various different natural family planning methods. In general, the better you get to know your body and to understand your ovulation patters, the more effective the method is at preventing unwanted pregnancy.
c) There are several barrier methods, including cervical caps, male and female condoms and diaphragms. The effectiveness can be improved with use of spermicide, and these have the added benefit of preventing transmission of STDs.
d) Lactational amenorrhea can be very effective if all of the following are met: the infant is less than 6 months old, exclusively breastfeeding on demand and has fewer than 4 hours between feeds during the day and fewer than 6 hours at night, and menses have not returned.

Answer 45

C