Module 5 Intrapartum Canvas Practice Questions

Question 1

It is most appropriate to delay admission to the birth site for labor until a woman is in active labor because early admission may increase:

A) the use of oxytocin.
B) the rate of cesarean birth.
C) the use of epidural analgesia.
D) all of the above.

Answer 1

D) all of the above.

Varney p. 881-883, 887. Supporting normal first-stage labor allows time for physiologic labors to unfold without unnecessary interventions. Accurately diagnosing active labor is of the utmost importance because…this phase serves as the basis for admission decisions are made and the need for intervention determined.

Question 2

A G1P0 at term with an unremarkable medical and prenatal history comes to the hospital for a labor evaluation. She has been contracting every 5-20 minutes for 6 hours. Vaginal exam results are 1 cm/25% effaced/-2 station. Teaching should include which information?

A) Admission to the hospital before active labor is associated with a higher rate of intervention.
B) CPD is a concern because the head is not engaged.
C) If this is false labor, the contractions will slow or stop with walking.
D) The location of the contractions is helpful in determining phase of labor.

Answer 2

A) Admission to the hospital before active labor is associated with a higher rate of intervention.

Question 3

A 28 y.o. G1P0 at 40 weeks has 12 hours of regular contractions which stop. This is most likely

A) normal early labor
B) arrest of active labor
C) an indication of a malposition
D) an indication for Pitocin augmentation

Answer 3

A) normal early labor

Varney p. 883 “Common signs and symptoms suggestive of physiologic progress toward labor include…(an) increase in uncoordinated uterine contractions.

Question 4

In a healthy woman with a term pregnancy in early labor, the occurrence of ketonuria is indicative of:

A) inadequate fluid intake.
B) concentrated urine.
C) inadequate nutrition.
D) dehydration.

Answer 4

C) inadequate nutrition.

Varney p. 896 Table 25-7

Question 5

According to Friedman, prolonged latent phase labor is defined as:

A) less than 1.2 cm/hour progress in a nulliparous woman and less than 1.5 cm/hour progress in a multiparous woman.
B) greater than 20 hours in a nulliparous woman and more than 14 hours in a multiparous woman.
C) more than 24 hours from the onset of contractions to 4 cm dilatation.
D) no cervical change in 2 hours.

Answer 5

B) greater than 20 hours in a nulliparous woman and more than 14 hours in a multiparous woman.

First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas: <20 hours

Multiparas: <14 hours

First Stage, Active phase:

Nulliparas: At least 1.2 cm/hr dilatation

Multiparas: At least 1.5 cm/hr dilatation

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

Source: NM 704 Modle 4 lecture

Question 6

According to Friedman, active labor is defined as the point when:

A) the rate of cervical dilatation increases sharply.
B) the woman reaches cervical dilatation of 3-4 cm.
C) the woman’s contractions change character.
D) contractions become every 2-3 minutes, 50-60 seconds long, and strong.

Answer 6

A) the rate of cervical dilatation increases sharply.

Varney p. 887. Both Friedman’s and contemporary studies define active labor as the point where cervical dilation accelerates. The disagreement is the typical cervical dilation where this increase in the rate of change can be expected.

Question 7

T/F: Management of prolonged latent phase, when intervention is appropriate, includes either augmentation of existing contractions or therapeutic rest, and is dependent on the woman’s emotional and physical condition.

Answer 7

True

Question 8

Supporting physiologic birth includes all of the following EXCEPT:

A) maintenance of nutrition and hydration.
B) clinician knowledge and skills
C) oxytocin augmentation if progress is less than 0.5 cm in the past hour.
D) support strategies to increase comfort and enhance coping.

Answer 8

C) oxytocin augmentation if progress is less than 0.5 cm in the past hour.

Varney p. 882 Table 25-1. Although oxytocin augmentation for dysfunctional labor may be appropriate, rigid time constraints disrupt normal physiologic birth. Contemporary understanding of active labor progress suggests cervical dilation is ON AVERAGE 0.5 cm/hour. One hour is too short a time frame to assess the adequacy of labor progress.

Question 9

Latent labor

A) is a time of happy emotions
B) can be diagnosed when contractions are every 10-20 minutes and last 10-20 seconds
C) is a time of fearful emotions
D) varies greatly person to person

Answer 9

D) varies greatly person to person

Varney p. 886 Although latent labor is characterized by uterine contractions increasing in frequency, duration, and intensity, no contraction parameters define latent labor. It may be a time of many emotions, no one feeling characterizes the experience. The emotional and physical aspects of latent labor vary from person to person and pregnancy to pregnancy.

Question 10

Water immersion during labor is associated with

A) a decrease in epidural use
B) an increase in perinatal mortality
C) hypertension
D) more reported pain

Answer 10

A) a decrease in epidural use

Varney p. 960. Water immersion during labor for pain relief is associated with decreased epidural use and reported pain. It is associated with no difference in labor duration, type of birth (ie cesarean or operative vaginal birth as compared to spontaneous vaginal birth), five minute Apgar Scores, neonatal infection and admission to neonatal units. It should be noted that water immersion during labor for pain relief is considered separately from water birth.

Question 11

Which of the following medication has the longest half life (and because of this the risk of respiratory depression in the newborn for the longest time period)?

A) Fentanyl
B) Merperidine (Demerol)
C) Morphine
D) Nalbuphine (Nubain)

Answer 11

B) Merperidine (Demerol)

Varney p. 967 Table 27-5. Demerol has, by far, the longest half-life of these four medications. (This is in part due to the action of its active metabolites.) This means that there is a long time period during which the neonate may experience respiratory depression if born following the administration of Demerol to the mother in labor.

Question 12

Side effects of epidural analgesia include

A) fever and hypertension
B) fever and hypotension
C) hypertension and urinary retention
D) fetal tachycardia and urinary retention

Answer 12

B) fever and hypotension

Varney p. 973, 975. Common side effects include fever, hypotension, postdural puncture headache, pruitis (if opiods used) and transient fetal heart rate decelerations.

Question 13

Which of the following is associated with a reduced cesarean birth rate?

A) Admission during latent phase
B) Continuous one-to-one labor support
C) Continuous electronic fetal monitoring
D) Epidural analgesia

Answer 13

B) Continuous one-to-one labor support

Varney p. 958 Continuous one-to-one labor support is associated with shorter labors, fewer cesarean births, less need for analgesia and anesthesia, less use of synthetic oxytocin, greater maternal satisfaction and increased maternal coping.

Question 14

The use of epidural analgesia is associated with:

A) an increased rate of cesarean birth
B) an increased rate of operative vaginal births
C) an increased rate of spontaneous vaginal births
D) shorter labors

Answer 14

B) an increased rate of operative vaginal births

Varney p. 975-976. Labor epidurals are associated with longer labors, more operative vaginal births, and more use of synthetic oxytocin. The effect of labor epidurals on cesarean birth rates is unclear. Some evidence shows an increased rate, some no difference.

Question 15

A 23-year-old G1P0 at 40 weeks had a negative Group B strep (GBS) culture at 37 weeks. Her membranes ruptured 22 hours before arriving at the hospital in labor. She is afebrile. Appropriate management includes

A) treating with penicillin G 5 million units IV now and repeat with 2.5 million units every 4 hours while in labor.
B) treating with clindamycin 900 mg IV now and repeat every 8 hours while in labor.
C) treating her with antibiotics only if she develops signs of intraamniotic infection.

Answer 15

C) treating her with antibiotics only if she develops signs of intraamniotic infection.

Question 16

A nullipara at 40 weeks is in active labor. She is 7 cm/100%/0 station. A urine dipstick shows 3+ ketones. Which of the following question is MOST relevant?

A) Can she tolerate oral intake?
B) Is her labor progressing normally?
C) What is her blood pressure?
D) What is her temperature?

Answer 16

A) Can she tolerate oral intake?

Varney p. 898-899. If a woman can tolerate oral intake, this is the preferred approach with ketonuria. While the questions may figure in management indirectly because they address possible indications for IV fluids, they are LESS relevant because they are not related to the issue of ketonuria.

Question 17

A 39 year old nullipara at 41 weeks is in active labor. She has an unremarkable medical, surgical, obstetrical and prenatal history. She is 7 cm/100%/0 station and has had no medications. She has progressed 3 cms in the past 3 hours. Which of the following is the best plan for her oral intake?

A) Diet as tolerated
B) Full liquids
C) Ice chips
D) NPO

Answer 17

A) Diet as tolerated

Varney p. 898. This woman is at low risk for anesthesia-related pulmonary aspiration. (Her age, gestation age, and labor progress are not risk factors.) Therefore NPO and ice chips only are not appropriate. In addition, NPO does not result in an empty stomach. Also, a full liquid diet is not easily digestible as it contains fat and milk products, so there is no advantage to this type of diet.

Question 18

Match diagnostic tests for rupture of membranes with causes for false positives: Nitrazine

A) Cervical mucus, semen
B) BV or trich, blood, lubricants, semen
C) high leak with minimal fluid
D) prolonged rupture of membranes
E) vaginal infection, semen, prelabor cervical ripening

Answer 18

B) BV or trich, blood, lubricants, semen

Question 19

Match diagnostic tests for rupture of membranes with causes for false positives: Fern

A) Cervical mucus, semen
B) BV or trich, blood, lubricants, semen
C) high leak with minimal fluid
D) prolonged rupture of membranes
E) vaginal infection, semen, prelabor cervical ripening

Answer 19

A) Cervical mucus, semen

Question 20

Match diagnostic tests for rupture of membranes with causes for false positives: Vaginal Pool

A) Cervical mucus, semen
B) BV or trich, blood, lubricants, semen
C) high leak with minimal fluid
D) prolonged rupture of membranes
E) vaginal infection, semen, prelabor cervical ripening

Answer 20

E) vaginal infection, semen, prelabor cervical ripening

Question 21

A pregnant woman has a history of genital herpes (HSV). Which of the following is correct regarding this woman’s labor and birth?

A) She should have a Cesarean delivery if she has not been taking antiviral medication.
B) The admitting provider will inquire about prodromal symptoms and examine her for presence of herpes lesions.
C) She should have a Cesarean delivery if her primary HSV outbreak occurred between 28 and 30 weeks.

Answer 21

B) The admitting provider will inquire about prodromal symptoms and examine her for presence of herpes lesions.

Question 22

A G1P0 at 39 weeks is admitted is to labor and delivery for prelabor rupture of membranes (PROM). According to the nurse midwife

A) birth within 24 hours results in the best outcomes.
B) expectant management is not recommended due to the increased risk of neonatal infection.
C) immediate induction is associated with an increased cesarean section rate as compared to expectant management.
D) avoiding a baseline vaginal exam and minimizing vaginal exams once in active labor is critical for reducing the risk of infection.

Answer 22

D) avoiding a baseline vaginal exam and minimizing vaginal exams once in active labor is critical for reducing the risk of infection.

Considerable evidence shows that number of vaginal exams is a significant factor in terms of risk of infection

Question 23

A nulliparous woman at 40 weeks is in labor. At 3 pm she is 6 cm/100%/-1 station. At 7 pm she is 7 cm/100%/-1 station. She is not experiencing back pain. The anterior fontanel is palpated in the right anterior portion of the pelvis. Which of the following statements is correct?

A) Her labor is progressing normally.
B) Her vaginal exam findings suggest a posterior position.
C) The position is not posterior because she is not experiencing back pain.
D) Vaginal exam finding suggest an anterior position.

Answer 23

B) Her vaginal exam findings suggest a posterior position.

Varney p. 658. Figure 19-16. Women may or may not experience back pain with any position, and vaginal exam findings are not always accurate. However, the vaginal exam findings is suggestive of a posterior position. Further, it should be noted that maternal position changes used to facilitate optimal fetal positioning and promote labor progress are not harmful even if the fetus is not malpositioned.

Question 24

You admit a multipara at 39 weeks in active labor. She is 4 cm/90%/0 station. She asks you to break her water. You should explain that routine amniotomy

A) is inappropriate at this gestational age
B) may decrease risk of cesarean section
C) may increase risk of cesarean section
D) substantially shortens labor

Answer 24

C) may increase risk of cesarean section

Varney p. 899-900 “AROM is women without dystocia was associated with a trend toward an increased risk for cesarean birth without a concomitant shortening of the first stage of labor.”

Question 25

Giving a woman in labor large amounts of IV fluids with dextrose is associated with

A) abnormal fetal heart rate patterns
B) an increased risk of cesarean birth
C) newborn jaundice and hypoglycemia
D) newborn polycythemia

Answer 25

C) newborn jaundice and hypoglycemia

This is from page 2 of the ACNM bulletin on Oral Nutrition in Labor: “In the 1960s and 1970s, IV dextrose was given in an attempt to reduce maternal ketosis. It soon became clear that in large doses, IV dextrose caused fetal lactic acidosis and newborn jaundice and hypoglycemia and this practice was discontinued.”

Question 26

You admit a multipara at 40 weeks in active labor. Her temperature is 101.9 degrees Fahrenheit. This temperature is most likely caused by:

A) a normal response to labor
B) an infectious process
C) dehydration
D) prolonged labor

Answer 26

B) an infectious process

Varney p. 1060-1061. A temperature increase of 1-2 degrees Fahrenheit may be normal in labor due to an expected increase in metabolism. While it may be normal, when a temperature elevation of 1-2 degrees Fahrenheit occurs, the midwife should rule out dehydration. This temperature elevation is more than that and most likely reflects an infectious process.

Question 27

A nullipara at 40 weeks is in active labor. Her dipstick urinalysis shows 3+ ketones. This result indicates:

A) dehydration
B) diabetes
C) inadequate caloric intake
D) prolonged labor

Answer 27

C) inadequate caloric intake

Varney p. 898. It is a common misconception that ketonuria indicates dehydration. When caloric needs exceed caloric intake, fat is burned for energy. A byproduct of this process is ketones in the urine. In laboring women it is common to see dehydration from inadequate fluid intake in women who also have ketonuria from inadequate caloric intake. This is because the reasons for inadequate intake of calories (for example nausea, vomiting, believing they should not eat and drink)often results in inadequate intake of fluids as well. In addition, if the dipstick is done on concentrated urine, the degree of ketonuria may be artificially magnified.

Question 28

An inlet with a short anteroposterior diameter and a wide transverse diameter is characteristic of which pelvic type?

A) Android
B) Anthropoid
C) Gynecoid
D) Platypelloid

Answer 28

D) Platypelloid

This is the only pelvic type in which the inlet is much longer from side to side (transverse) than from front to back (anteroposterior). The drawing of p.35 of Oxorn illustrates this well.

Question 29

During a routine placental inspection the midwife notes hard, nodular, whitish areas noted over the maternal surface of the placenta. This is likely a result of:
A) Congenital defects
B) Maternal anemia
C) Normal placental aging
D) Rh iso-immunization

Answer 29

C) Normal placental aging

Question 30

Which of the following describes a fetal presentation?

A) Asynclitic
B) Cephalic
C) Oblique
D) Posterior

Answer 30

B) Cephalic

Oxhorn p. 66-68 and Varney p. 655 Table 19-6. p. 657-659. Presentation is determined by the first portion of the fetus to enter to pelvis. Possible presentations are cephalic, breech and shoulder.

Question 31

When engagement has occurred the:

A) Biparietal diameter is at zero station
B) Head has rotated
C) Lowest level of the presenting part has reached the level of the ischial spines
D) Widest diameter of the fetal head has reached the midplane

Answer 31

C) Lowest level of the presenting part has reached the level of the ischial spines

Remember that there are two different ways to define engagement. One definition using the BPD as the reference point, the other uses the top of the head. Engaged= BPD has passed through the inlet (cannot feel this clinically via vaginal exam) ALSO=top of the head at the level of the ischial spines (can feel clinically via vaginal exam). Varney p. 869 & Oxhorn 78-80.

Question 32

What happens when the fetal head stimulates the stretch receptors in the pelvic floor muscles?
A) Early decelerations occur
B) Levels of endogenous oxytocin are increased
C) Rotation occurs
D) The risk of perineal lacerations increases

Answer 32

B) Levels of endogenous oxytocin are increased

Question 33

Where in the myometrium do uterine contractions of normal labor begin?
A) Cervix
B) Fundus
C) Lower uterine segment
D) Mid-uterus

Answer 33

B) Fundus

Question 34

Restitution occurs as a result of the:

A) Internal rotation of the shoulders
B) Release of extension after birth
C) Rotation from a posterior to an anterior position
D) Untwisting of the neck after birth of the head

Answer 34

D) Untwisting of the neck after birth of the head

During internal rotation the head rotates more than the rest of the body and the fetal head is out of its natural alignment with the body. After the head is born, it spontaneously returns to this natural alignment. Varney p. 871-873.

Question 35

To determine the station of the fetus you would:

A) Identify the cephalic prominence
B) Identify the sagittal suture
C) Palpate the ischial spines
D) Palpate the sacral promontory

Answer 35

C) Palpate the ischial spines

Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. Varney p. 869. Oxhorn p. 96

Question 36

What is the benefit of asynclitism?
A) Allows fetal head to descend without molding
B) Decreases biparietal diameter presented to the pelvic inlet
C) Facilitates internal rotation
D) Posterior rotation is prevented

Answer 36

B) Decreases biparietal diameter presented to the pelvic inlet

Question 37

The mechanisms of labor are:

A) Dilation and descent
B) The positional changes the fetus undergoes to accommodate itself to the maternal pelvis
C) Latent phase, acceleration phase, phase of maximum slope and deceleration phase
D) Preparatory phase, dilatation phase and pelvic phase

Answer 37

B) The positional changes the fetus undergoes to accommodate itself to the maternal pelvis

Which are (for a occiput anterior position) engagement, descent, flexion, internal rotation, extension, restitution. external rotation. Varney p. 874

Question 38

Flexion of the fetal head during labor results in:

A) Alignment of the long axis of the head with the long axis of the pelvic inlet
B) Malpresentation
C) Pivoting of the head under the symphysis pubis
D) The presentation of a smaller diameter

Answer 38

D) The presentation of a smaller diameter

The size of the presenting diameter of the fetal head is impacted by the attitude, meaning the degree of flexion or extension. Fully flexed and fully extended both present the smallest diameter. Paritial flexion or extension and no flexion or extension present larger diameters. Varney p. 656 Table 19-6, p. 658 Figure 9-15. Oxhorn p. 66-69.

Question 39

To determine the attitude of the fetus you would:

A) Identify the cephalic prominence
B) Identify the sagittal suture
C) Palpate the ischial spines
D) Palpate the sacral promontory

Answer 39

A) Identify the cephalic prominence

The cephalic prominence is felt via abdominal exam. It is the side on which the fetal head is felt most prominently during abdominal palpation. The location of the cephalic prominence is determined by flexion or extension. Oxhorn p. 93

Question 40

To determine the position of the fetus you would:

A) Identify the cephalic prominence
B) Identify the sagittal suture
C) Palpate the ischial spines
D) Palpate the sacral promontory

Answer 40

B) Identify the sagittal suture

To ascertain the fetal position via vaginal exam, the sagittal suture is identified, then used to locate the fontanelle in the anterior portion of the pelvis. Oxhorn p. 96

Question 41

The sagittal suture of the fetal head:

A) Is located over the occiput
B) Lies between the parietal bones
C) Runs in a transverse direction
D) Separates the occipital bones from the two parietals

Answer 41

B) Lies between the parietal bones

The parietal bones are the two large bones on the skull on either side of the head. They are important landmarks for a variety of reasons. The sagittal suture runs right across the top of the head and is also an important landmark. The drawing on p. 43 of Oxorn illustrates this well.

Question 42

When engagement has occurred the:

A) Biparietal diameter has reached the inlet
B) Biparietal diameter has reached the ischial spines
C) Head has extended
D) Widest diameter of the fetal head has reached the midplane

Answer 42

A) Biparietal diameter has reached the inlet

Remember that there are two different ways to define engagement. One definition using the BPD as the reference point, the other uses the top of the head. Engaged= BPD has passed through the inlet (cannot feel this clinically via vaginal exam) ALSO=top of the head at the level of the ischial spines (can feel clinically via vaginal exam). Varney p. 869 & Oxhorn 78-80.

Question 43

Which of the following is a fetal attitude?

A) Asynclitic
B) Cephalic
C) Flexion
D) Transverse

Answer 43

C) Flexion

Attitude refers to the degree of flexion or extension of the fetal head. Oxhorn p. 66 & 72. Varney 657 & 658.

Question 44

The midwife is considering various analgesic options to offer. Sterile water papules would be the best choice for which woman?
A) A woman with dysfunctional latent labor contractions.
B) A G1 P0 who is pushing and has severe perineal pain.
C) A G5 P4 who has severe back pain and cervical exam is 5/75/-2.
D) A woman undergoing an external cephalic version.

Answer 44

C) A G5 P4 who has severe back pain and cervical exam is 5/75/-2.

Varney p. 961 “the therapeutic goal is to relieve back pain in labor”.

Question 45

A G1 P0 is requesting pain management other than epidural anesthesia. She is coping well, breathing and rocking on a birthing ball. Labor admission was 4 hours ago. Cervical exam at admission was 6 cm/75% effaced/-1 station. Spontaneous rupture of membranes happened about 1 hour ago. FHR by intermittent auscultation is in the 140’s with no decelerations during or after contractions. Cervical exam now is 8 cm/100% effaced /0 station with clear fluid noted, vertex presentation, and ROA position. Which of the following statements is TRUE regarding opioid pain medication?
A) Fentanyl (sublimaze) can be safely administered in advanced first stage labor
B) Demerol (meperidine) has the shortest half-life of common opioid medications
C) Stadol (Butorphanol) is not associated with acute opioid withdrawal syndrome
D) No opioid medication can be safely administered in advanced first stage labor

Answer 45

A) Fentanyl (sublimaze) can be safely administered in advanced first stage labor

Varney P. 967-968 “Fentanyl has a short half-life so it has not been associated with neonatal respiratory depression. Due to its short duration of action, it is well suited for administration toward the end of the first stage of labor…”

Question 46

A G3P2 at term comes to the maternity unit for a labor evaluation. She has been contracting off and on for several days. The contractions are now every 6-15 minutes. She states she is very tired because the contractions have interrupted her sleep the last 3 nights and she has had about 4-5 hours per night of sleep. Her vitals signs are normal, the fetal heart rate tracing is category one and vaginal exam is 3 cm dilated, 50% effaced with the head it at -2 station. What is the best management plan?
A) Advise her to go home to active labor.
B) Augmentation with oxytocin for prolonged latent phase.
C) Therapeutic rest at home with Ambien®.
D) Therapeutic rest in the hospital with morphine sulfate.

Answer 46

D) Therapeutic rest in the hospital with morphine sulfate.

Since the parturient is experiencing painful contractions that are interrupting her sleep, the most appropriate medication is one that treats pain. NM704 Module 5 lecture content: “Giving a woman medication to sleep, often called therapeutic rest, can be a useful measure. Often the woman will sleep for a few hours and wake up either without contractions or in active labor. Narcotic analgesics are generally used, since other medications such as sleeping pills have no pain-relieving properties. Morphine is traditionally used, though Nubain® and Stadol® are also reasonable options. Most clinicians want the woman to stay in the hospital when these medications are used. As with any intervention, the risks and benefits of therapeutic rest should be thoroughly discussed.”

Question 47

A G6 P3023 at 40 5/7 weeks gestation with an uncomplicated prenatal course is admitted to the birthing unit for labor evaluation. Vital signs are normal, and fetal status is reassuring based on a 20-minute fetal monitoring tracing. Contractions are every 3-4 minutes and strong by palpation. Cervical exam is 6 cm/75%/0 station, and the woman complains of severe back pain. The best choice for relieving her back pain is:
A) Nubain 10 mg IV
B) Pudendal block
C) Semi-Fowler’s position
D) Intracutaneous sterile water papules

Answer 47

D) Intracutaneous sterile water papules

Varney p. 961. “The therapeutic goal (of sterile water injections) is to relieve back pain”.

Question 48

Which factor is most likely to cause an elevated temperature in a woman with an otherwise normal labor?
A) Use of epidural
B) Use of dinoprostone (Cervidil)
C) Immobility
D) Exhaustion

Answer 48

A) Use of epidural

Varney p 975. “an increase in the incidence of maternal fever…has been demonstrated in women who have epidural analgesia in labor”.

Question 49

Do labor epidurals increase the risk of cesarean birth?

A) No
B) Only if given in latent labor
C) The evidence is conflicting
D) Yes

Answer 49

A) No

Varney p. 976 “epidural analgesia is not associated with an increase in cesarean birth”. A Cochrane review of RCT published in 2018 did not demonstrate a relationship between epidural anesthesia and cesarean birth. Critics have pointed out methodological issues with some of the included studies but it is the highest quality evidence currently available to understand this relationship.

Question 50

What is the impact of labor epidurals on the length of the second stage of labor?
A) The evidence is unclear
B) Epidurals always shorten second stage labor
C) The relationship depends on the parity of the woman
D) There is no relationship between epidural use and length of the second stage of labor

Answer 50

A) The evidence is unclear

Varney p. 975-976. “The effect of epidural analgesia on the duration of labor is difficult to determine due to many confounding factors.” Retrospective studies have suggested an association between epidural analgesia and longer 1st and 2nd stage labor. Meta-analyses of RCT’s have not demonstrated an association between epidurals and length of second stage labor.

Question 51

Informed consent about epidurals should include all of the following EXCEPT:
A) Increased chance of limited maternal mobility
B) Increased incidence of operative deliveries
C) Increased length of second stage labor
D) Increased neonatal infections

Answer 51

D) Increased neonatal infections

Varney p. 973-776 epidural anesthesia is associated with more neonatal sepsis evaluations but not more neonatal sepsis.

Question 52

A G4 P3 at 40 weeks gestation has experienced an uncomplicated pregnancy and labor. Her first labor was on the long side but ended with a normal spontaneous vaginal birth. She was admitted for labor 2 hours ago for active labor and spontaneous rupture of membranes. She had been moaning loudly with contractions every 2-3 minutes. The last fetal heart tone assessment via intermittent auscultation was 5 minutes ago and are as follows: FHR was 150 bpm with no decelerations heard during or after the contraction. For the last 30 minutes, her contractions have been less frequent and she is breathing through contractions with her eyes closed. She states her contractions seem to be spacing out and requests a cervical exam revealing a cervix that is completely dilated and the fetal head is at -1 station, clear fluid noted. The most likely explanation for the spacing out of her contractions and lack of urge to push is:

A) impending uterine rupture
B) cephalopelvic disproportion
C) the fetal station
D) prolonged second stage

Answer 52

C) the fetal station

Varney p. 985. “If the fetus is above 0 station when the cervix becomes completely dilated, the first phase of the second stage may consist of a short lull or pause during which uterine contractions are less frequent and there is no urge to push.”

Question 53

Persistent OP presentation in the second stage of labor

A) may be difficult to determine when the fetus is deep in the pelvis
B) is associated with deep transverse arrest
C) is associated with fewer perineal lacerations
D) is associated with induction of labor with oxytocin

Answer 53

A) may be difficult to determine when the fetus is deep in the pelvis

Varney p. 989-990 “Although ultrasound is more accurate than digital examination, approximately 6-10% of ultrasounds are not able to determine the fetal position, particularly when the fetus is deep in the pelvis.”

Question 54

The anatomical definition of second stage labor is:

A) the time from 8cm dilatation and ending with expulsion of the fetus.
B) the time from complete dilatation and ending with expulsion of the fetus.
C) the time beginning with the urge to push and ending with expulsion of the fetus.
D) the time beginning with the fetal presenting part reaching +1 station and ending with expulsion of the fetus.

Answer 54

B) the time from complete dilatation and ending with expulsion of the fetus.

Varney p. 985. “anatomically, second stage labor is defined as beginning with complete dilation of the cervix and ending with expulsion of the fetus.”

Question 55

The physiological definition of second stage labor is:

A) the time from complete dilatation to expulsion of the fetus.
B) the time from 8 cm to expulsion of the fetus.
C) the time beginning with involuntary bearing down and ending with expulsion of the fetus.
D) the time beginning with descent noted with coached pushing to expulsion of the fetus..

Answer 55

C) the time beginning with involuntary bearing down and ending with expulsion of the fetus.

Varney p. 985 “…physiologic…second stage may be defined as the onset of the urge to bear down until the birth of the infant”

Question 56

The length of normal second-stage labor

A) is 2 hours when the fetus is in a persistent OP presentation
B) is not straight forward to determine
C) has not been studied using contemporary criteria for labor progress
D) is associated with adverse neonatal outcomes in nulliparous women

Answer 56

B) is not straight forward to determine

Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery p. 9 “Defining what constitutes an appropriate duration of the second stage is not straightforward because it involves a consideration of multiple short-term and long-term maternal and neonatal outcomes––some of them competing. “

Question 57

A G2P1 is completely dilated with an urge to push. The fetal head is at a +1 station. Which is the best plan?
A) Discourage pushing until the head is at a lower station.
B) Don’t allow the woman to pushed with a closed glottis.
C) Encourage pushing when the urge is felt.
D) Instruct the woman to hold her breathe and push to the count of ten, trying for three times with each contraction.

Answer 57

C) Encourage pushing when the urge is felt.

Question 58

An evidence-based technique for perineal management during birth that decreases or minimizes genital tract trauma is:

A) avoiding touching the perineum or fetal head until crowning
B) perineal massage with lubricant on the perineum as the fetal head crowns.
C) birth of the fetal head with expulsive efforts during a contraction.
D) avoiding the lithotomy position

Answer 58

D) avoiding the lithotomy position

Varney p. 997-998 “Squatting is associated with more second-degree lacerations…”

Question 59

The Fetal Ejection Reflex

A) typically occurs when the fetus reaches +1 station
B) typically occurs at 10 cm dilation
C) typically occurs when the fetal head is visible at the introitus
D) typically occurs after oxytocin augmentation

Answer 59

A) typically occurs when the fetus reaches +1 station

Varney p. 985. “The physiologic urge to push (fetal ejection reflex) typically occurs when the fetal presenting part reaches +1 station.”

Question 60

A 31-year-old primigravida at term has been in active labor for 8 hours and has dilated 2 cm in the past 2 hours. The woman requests that the midwife rupture her membranes to “speed things up.” Which is true regarding artificial rupture of membranes (AROM) for this woman?
A) indicated because of lack of adequate labor progress
B) appropriate as a routine intervention for this woman
C) may contribute to fetal heart decelerations
D) will likely lead to infection

Answer 60

C) may contribute to fetal heart decelerations

Varney p. 899-900. ACOG does not recommend routine amniotomy during normally progressing labor unless required to facilitate monitoring. “Risks associated with AROM include umbilical cord compression with resultant FHR decelerations.”

Question 61

A 39-year-old G5P4 at 42 weeks is admitted for a planned induction. Leopold maneuvers reveal the long axis of the fetus is perpendicular to the long axis of the mother. Upon digital exam the cervix is found to be 1 cm/25%/medium/middle/out of the pelvis (bishop score 3). Mild, irregular contractions are occurring. In this situation
A) artificial rupture of membranes should be done to induce labor.
B) induction of labor is contraindicated
C) oxytocin is the best choice for induction.
D) prostaglandins should be used for cervical ripening.

Answer 61

B) induction of labor is contraindicated

ACOG Practice Bulletin No. 107: Induction of Labor p. 5 transverse lie (fetus is PERPENDICULAR to the long axis of the abdomen) is a contraindication to induction of labor.

Question 62

Which of the following is TRUE regarding mechanical cervical ripening with a foley balloon catheter?
A) Foley catheter balloons are associated with lower incidence of uterine tachysystole compared to prostagladin
B) Foley catheter balloons are the least common method of cervical ripening.
C) Foley catheter balloons used before oxytocin induction do not reduce the length of labor
D) Foley catheter balloons are contraindicated for women with a history of low-transverse uterine incision

Answer 62

A) Foley catheter balloons are associated with lower incidence of uterine tachysystole compared to prostagladin

ACOG Practice Bulletin No. 107: Induction of Labor p. 2&5. Varney p. 1064 “Advantages of the Foley catheter include low cost when compared with prostaglandins, stability at room temperature, and reduced risk of uterine tachysystole with or without fetal heart rate (FHR) changes”.

Question 63

Which is the most likely side effect of misoprostol when used for cervical ripening prior to oxytocin administration?
A) Hypotension
B) Maternal fever
C) Nausea and vomiting
D) Tachysystole

Answer 63

D) Tachysystole

ACOG Practice Bulletin No. 107: Induction of Labor p. 5 “Tachysystole with or without FHR changes is more common with vaginal misoprostol compared with vaginal prostaglandin E2, intracervical prostaglandin E2, and oxytocin.”

Question 64

During an oxytocin induction, a woman has increased uterine resting tone and contractions about 2 minutes apart. Appropriate management is:
A) Prepare the patient for a Cesarean section.
B) Reposition the patient and increase IV fluids,
C) Turn off the oxytocin
D) Administer oxygen 10 L/min via non-rebreather

Answer 64

C) Turn off the oxytocin

ACOG Practice Bulletin No. 107: Induction of Labor p. 7; Varney p. 1067. The first step to manage tachysystole (more than 5 contractions in a 10-minute period averaged over 30 minutes) during oxytocin induction is to stop the oxytocin infusion. Other management techniques such as increasing IV fluids and repositioning the patient may be employed but the tachysystole will not resolve unless the oxytocin infusion is stopped.

Question 65

A 40 week G1P0, whose cervical exam is 1 cm/50% effaced/-2/soft/middle (bishop score 6), asks the midwife if there is anything she can do to increase the likelihood of her going into spontaneous labor. According to evidence-based research
A) membrane stripping has the potential of encouraging labor.
B) walking 30 minutes every day will stimulate labor.
C) evening primrose oil capsules vaginally or orally will decrease the risk of a late-term pregnancy.
D) blue and black cohosh are considered safe for use in pregnancy.

Answer 65

A) membrane stripping has the potential of encouraging labor.

Varney p. 791. “Evidence shows a reduced rate of pregnancy extending beyond 41 weeks with membrane sweeping.”

ACOG Practice Bulletin No. 107: Induction of Labor p.3 “Stripping membranes increases the likelihood of spontaneous labor within 48 hours and reduces the incidence of induction with other methods”

Question 66

Which is the most likely side effect of dinoprostone and misoprostol?
A) Hypotension
B) Maternal fever
C) Nausea and vomiting
D) Uterine hyperstimulation

Answer 66

D) Uterine hyperstimulation

Varney p. 1065 Table 29-7. Both misoprostol and dinoprostone require continuous inpatient FHR monitoring due to the side effect of tachysystole.

Question 67

Cervical ripening agents are indicated for
A) Bishop score less than 6
B) Bishop score greater than 8
C) prolonged latent phase
D) prolonged active phase

Answer 67

A) Bishop score less than 6

ACOG Practice Bulletin No. 107: Induction of Labor p 2. “An unfavorable cervix generally has been defined as a Bishop score of 6 or less in most randomized trials. If the total score is more than 8, the probability of vaginal delivery after labor induction is similar to that after spontaneous labor.”

Question 68

A woman is scheduled for induction and has a Bishop’s score of 4. Which is the LEAST appropriate cervical ripening agent?
A) Oxytocin
B) Cervidil
C) Cytotec
D) Foley bulb

Answer 68

A) Oxytocin

ACOG Practice Bulletin No. 107: Induction of Labor p. 2

Effective methods for cervical ripening include the use of mechanical cervical dilators and the administration of synthetic prostaglandin E1(PGE1) and prostaglandin E2(PGE2). Mechanical dilation methods are effective in ripening the cervix and include hygroscopic dilators, osmotic dilators (Laminaria japonicum), Foley catheters with inflation volume of 30–80 mL,double-balloon devices (Atad Ripener Device), and extraamniotic saline infusion using infusion rates of 30–40 mL/h”.

Question 69

Prolonged exposure to oxytocin may increase the risk for
A) chorioamnionitis
B) maternal fever
C) postpartum hemorrhage
D) maternal EKG changes

Answer 69

C) postpartum hemorrhage

Varney p. 1067 “prolonged use of oxytocin can lead to downregulation of oxytocin receptors, added risk of tachysystole, less effective uterine contractions (and) can also increase the risk of postpartum hemorrhage… Active management of 3rd stage labor should be considered.”

Question 70

Compared with lose dose oxytocin regimens, high dose regimens are associated with
A) a higher rate of cesarean births
B) less prostagladin use
C) longer labor
D) more uterine tachysystole

Answer 70

D) more uterine tachysystole

Varney p. 1067 “high doses regimens are associated with more uterine tachysystole, a shorter interval between starting oxytocin and adequate labor, and shorter duration of labor. The evidence regarding cesarean birth rates with higher versus lower dose regimens have been inconsistent.”

Question 71

The risk of hyperstimulation with misoprostol is related to the
A) dosage used
B) gestational age
C) indication for use
D) parity of the woman

Answer 71

A) dosage used

ACOG Practice Bulletin No. 107: Induction of Labor p. 6. “One-quarter of an unscored 100-mcg tablet (ie, approximately 25 mcg) of misoprostol should be considered as the initial dose for cervical ripening and labor induction… Misoprostol in higher doses (50 mcg every 6hours) may be appropriate in some situations, although higher doses are associated with an increased risk of complications, including uterine tachysystole with FHR decelerations”

Question 72

Friedman defined the onset of active labor as occurring when the
A) cervical dilation reaches 3 centimeters
B) cervix is fully effaced
C) contractions are less than 5 minutes apart and painful
D) rate of dilation sharply increases

Answer 72

D) rate of dilation sharply increases

In Friedman’s framework, the first stage of labor begins with the onset of regular uterine contractions and ends with complete dilation of the cervix. First stage is further divided into latent and active phase. This is based on the observation that progress at the beginning of labor is slow, followed by a distinct increase in the rate of progress. This upswing is defined as the beginning of active phase.

Source; NM 704 Module 4 lecture content

Question 73

Contemporary research shows that the onset of active labor occurs
A) at or after 5 or 6 centimeters dilation in many women
B) earlier in labor than previously understood
C) prior to complete effacement
D) when contractions are less than 5 minutes apart and painful

Answer 73

A) at or after 5 or 6 centimeters dilation in many women

Varney p. 888. The cervical dilation when dilation begins to accelerate (active labor) is around 5-6 cm according to the Consortium on Safe Labor study.

Question 74

A primigravida in normal active labor is 7 cm dilated at 1:00 p.m. and 8 cm dilated at 5:00 p.m. According to Friedman’s criteria, this is:
A) normal labor progress
B) prolonged latent phase
C) protracted active phase
D) secondary arrest of dilation

Answer 74

C) protracted active phase

The Friedman criteria most commonly used in clinical practice (and what you are expected to memorize for this course) are the following:

First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas: <20 hours

Multiparas: <14 hours

First Stage, Active phase:

Nulliparas: At least 1.2 cm/hr dilatation

Multiparas: At least 1.5 cm/hr dilatation

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

Source: NM 704 Module 4 lecture content

Question 75

According to Friedman’s curve, the minimal acceptable rate of dilatation during the phase of maximum slope (normal active phase labor) in a NULLIPARA is:
A) 1 cm per hour
B) 1.2 cm per hour
C) 1.5 cm per hour
D) 2 cm per hour

Answer 75

B) 1.2 cm per hour

The Friedman criteria most commonly used in clinical practice (and what you are expected to memorize for this course) are the following:

First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas: <20 hours

Multiparas: <14 hours

First Stage, Active phase:

Nulliparas: At least 1.2 cm/hr dilatation

Multiparas: At least 1.5 cm/hr dilatation

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

Source: NM 704 Module 4 lecture content

Question 76

A G1P0 at 40 weeks is in active labor. At noon her cervical exam is 6 cm/100% effaced/0 station. At 3 pm her cervical exam is 8 cm/100% effaced/0 station. According to contemporary criteria her labor progress is
A) arrested
B) dysfunctional
C) normal
D) prolonged

Answer 76

C) normal

Varney p. 887-891. Across contemporary studies, a common slowest yet normal rate of dilation during active phase for both nullips and multips is 0.5 cm/hr on average.

Question 77

A G2 P1 at 40 weeks is admitted with contractions every 2-4 minutes and a cervical exam of 6 cm/90%/-2 station. Two hours later her contraction pattern is unchanged and her cervical exam is 8 cm/100%/-1 station. According to Friedman criteria, this labor progress is:
A) Arrested
B) Normal
C) Prodromal
D) Protracted

Answer 77

D) Protracted

The Friedman criteria most commonly used in clinical practice (and what you are expected to memorize for this course) are the following:

First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas: <20 hours

Multiparas: <14 hours

First Stage, Active phase:

Nulliparas: At least 1.2 cm/hr dilatation

Multiparas: At least 1.5 cm/hr dilatation

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

Source: NM 704 Module 4 lecture content

Question 78

Contemporary research on diagnosing and managing slow labor
A) clarifies when interventions are needed
B) clarifies when slow labor is associated with perinatal complications
C) does not provide clear recommendations for appropriate timing of interventions
D) shows that commonly used protocols do not recommend intervening soon enough

Answer 78

C) does not provide clear recommendations for appropriate timing of interventions

The Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. describes when to consider cesarean birth after oxytocin administration but not when to consider oxytocin administration for managing slow labor.

Question 79

How many hours of oxytocin augmentation for protracted or arrested labor results in more vaginal births without increasing the rate of low Apgar scores, asphyxia or birth injury?

A) 8 hours
B) 4 hours
C) 2 hours
D) 12 hours

Answer 79

A) 8 hours

Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery p. 7. “… women who received at least 4 additional hours of oxytocin, 38% delivered vaginally, and none had neonates with 5-minute Apgar scores of less than 6. In nulliparous women, a period of 8 hours of augmentation resulted in an 18% cesarean delivery rate and no cases of birth injury or asphyxia, whereas if the period of augmentation had been limited to 4 hours, the cesarean delivery rate would have been twice as high given the number of women who had not made significant progress at 4 hours. Thus, slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery.”

Question 80

G1 P0 is admitted in active labor. At 1600 her cervical exam is 7cm/100%/0 station. Two hours later her cervical exam reveals 8cm/100%/+1 station. According to Friedman’s criteria, her labor progress is:

A) Normal
B) Protracted
C) Disordered
D) Arrested

Answer 80

B) Protracted

First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas: <20 hours

Multiparas: <14 hours

First Stage, Active phase:

Nulliparas: At least 1.2 cm/hr dilatation

Multiparas: At least 1.5 cm/hr dilatation

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

Source: NM704 Module 4 lecture

Question 81

G2 P1001 in active labor is 10cm/100%/0 station. She has no urge to push. An hour later, Nicki’s cervical exam is 10cm/100%/+2 station. According to Friedman’s criteria, Nicki’s labor progress is:

A) Normal
B) Protracted
C) Disordered
D) Arrested

Answer 81

A) Normal

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

(Although descent may begin during the first stage of labor, protracted and arrested descent can only be diagnosed in second stage.)

Source: NM 704 Module 4 lecture

Question 82

Admission to the hospital in the latent phase of labor may result in:

A) An increased rate of intrapartum interventions
B) Decreased use of pain medication in active labor
C) Improved perinatal outcomes
D) Lower cesarean birth rates

Answer 82

A) An increased rate of intrapartum interventions

Varney p. 892. Women who are admitted in early labor are more than twice as likely to receive oxytocin augmentation or cesarean birth than women admitted in active labor.

Question 83

According to Friedman, active labor begins when the:

A) Cervix is 4cm dilated
B) Contractions become more painful
C) Contractions are occurring every 3-4 minutes
D) Rate of dilatation changes abruptly

Answer 83

D) Rate of dilatation changes abruptly

Varney p. 887-888. Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery p. 5 & 6. Both Friedman and contemporary research support the definition of active labor as when the rate of cervical dilation increases sharply. Friedman describes the first portion of active labor as the “acceleration phase”. The difference between Friedman and contemporary understanding of the onset of active labor is at what dilation this “inflection point” of rapid dilation typically takes place, not the defining characteristics of active labor.

Question 84

Active labor can be reliable diagnosed based on

A) cervical dilation alone
B) the patient’s affect
C) parity
D) after ongoing assessment for 2 to 4 hours

Answer 84

D) after ongoing assessment for 2 to 4 hours

Varney p. 897 “unless labor is clearly advanced, a single cervical dilation measurement does not reliably differentiate phases of labor… it may take several hours of ongoing assessment to differentiate between prelabor, latent labor, and active labor.”

Question 85

Arrested second stage is defined as more than 3 hours of pushing

A) for those with epidural analgesia
B) for multigravidas
C) for those diagnosed with prolonged active phase of labor
D) for primigravidas

Answer 85

D) for primigravidas

Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery p. 7 Table 3.

Before diagnosing arrest of labor in the second stage, if the maternal and fetal 1Bconditions permit, allow for the following:

*At least 2 hours of pushing in multiparous women

*At least 3 hours of pushing in nulliparous women

(Strong recommendation, moderate-quality evidence)

Question 86

A woman is in early active labor with ruptured membranes. The midwife auscultates fetal heart tones most clearly over the right upper quadrant of the woman’s abdomen. Which is the most appropriate action?

A) perform a vaginal examination.
B) encourage ambulation.
C) consult with the consultant physician.
D) obtain an ultrasound.

Answer 86

D) obtain an ultrasound.

Question 87

During a breech delivery it is critical to maintain the fetal head in the

A) occiput anterior flexed position.
B) occiput transverse flexed position.
C) occiput posterior flexed position.

Answer 87

A) occiput anterior flexed position.

Question 88

Which is associated with breech presentation?

A) Obesity
B) Prematurity
C) Macrosomia
D) Postmaturity

Answer 88

B) Prematurity

Question 89

The presenting diameter of a brow presentation is

A) larger then a well flexed vertex presentation.
B) the same size as a well flexed vertex presentation.
C) smaller than a military presentation.
D) smaller than a face presentation.

Answer 89

A) larger then a well flexed vertex presentation.

Question 90

A G2P1001, with a history of a previous low transverse cesarean section, arrives in active labor desiring a trial of labor. To increase the likelihood of identifying a uterine rupture the midwife recommends

A) continuous fetal heart rate monitoring.
B) the use of an intrauterine pressure catheter.
C) the use of an internal scalp electrode.
D) avoidance of epidural anesthesia.

Answer 90

A) continuous fetal heart rate monitoring.

Question 91

A G1P0 at 39 weeks is admitted is to labor and delivery for prelabor rupture of membranes (PROM). According to the nurse midwife

A) expectant management is not recommended due to the increased risk of neonatal infection.
B) birth within 24 hours results in the best outcomes.
C) immediate induction is associated with an increased cesarean section rate as compared to expectant management.
D) avoiding a baseline vaginal exam and minimizing vaginal exams once in active labor is critical for reducing the risk of infection.

Answer 91

D) avoiding a baseline vaginal exam and minimizing vaginal exams once in active labor is critical for reducing the risk of infection.

Varney p. 1060 Vaginal exams are associated with intra-amniotic infection. Vaginal exams are a modifiable risk factor for infection and their judicious use after membranes rupture is an important component of midwifery practice.

Question 92

Which statement about diabetes and shoulder dystocia is TRUE?

A) Diabetes is a risk factor for shoulder dystocia only if the fetal weight exceeds 4500 grams.
B) Diabetes is a risk factor for shoulder dystocia because it impacts the head to shoulder ratio.
C) Diabetes is a risk factor for shoulder dystocia only if a woman has uncontrolled blood sugars.

Answer 92

B) Diabetes is a risk factor for shoulder dystocia because it impacts the head to shoulder ratio.

Question 93

After a prolonged labor with oxytocin augmentation, a G1P0 delivers a 7 lb 5 oz baby. The placenta is delivered with umbilical cord traction prior to signs of separation and appears intact. Heavier than normal bleeding is noted. Attempts to locate the fundus for massage aren’t successful. Further exploration uncovers a soft mass in the cervical opening. Risk factors for this delivery complication include

A) nulliparity.
B) anterior placenta.
C) umbilical cord traction prior to placenta separation.
D) the baby is LGA

Answer 93

C) umbilical cord traction prior to placenta separation.

Varney p. 1116-1117. Mismanagement of the third stage of labor by applying cord traction before signs of separation is associated with complications such as hemorrhage and uterine inversion

Question 94

Which factor can trigger an immune response in the blood stream that may result in an embolus?

A) fat
B) air
C) malignant neoplasm
D) amniotic fluid

Answer 94

D) amniotic fluid

Question 95

A 28-year-old G2P1 is actively laboring. Which of the following is most suggestive of intraamniotic infection (chorioamnionitis)?

A) maternal fever and leukocytosis.
B) fever in a woman with an epidural.
C) fetal bradycardia and uterine hyperstimulation.
D) maternal hypotension and fetal late decelerations

Answer 95

A) maternal fever and leukocytosis.

Question 96

Evidence shows that when thick meconium-stained fluid is evident, endotracheal intubation and suctioning

A) is improved by suctioning of the oropharynx before delivery of the shoulders .
B) is required only in preterm infants.
C) will prevent Meconium Aspiration Syndrome (MAS).
D) may cause bradycardia or injury.

Answer 96

D) may cause bradycardia or injury.

Question 97

A G2P1001, with a history of a previous low transverse cesarean section, arrives in active labor desiring a trial of labor. To increase the likelihood of identifying a uterine rupture the midwife recommends

A) avoidance of epidural anesthesia.
B) the use of an intrauterine pressure catheter.
C) the use of an internal scalp electrode.
D) continuous fetal heart rate monitoring.

Answer 97

D) continuous fetal heart rate monitoring.

Varney p. 1074 Table 29-9. Either CEFM or Q. 15 minutes IA in active labor is a principle of safe management for TOLAC

Question 98

SATA: After a prolonged labor with oxytocin augmentation, a G1P0 delivers a 7 lb 5 oz baby. The fundal placenta is delivered with umbilical cord traction prior to signs of separation and appears intact. Heavier than normal bleeding is noted. Attempts to locate the fundus for massage aren’t successful. Further exploration uncovers a soft mass in the cervical opening. Risk factors for this delivery complication include

A) uterine atony.
B) nulliparity.
C) umbilical cord traction prior to placenta separation.
D) fetal weight of 7 lb 5 oz
E) fundal placental implantation.

Answer 98

A) uterine atony.
C) umbilical cord traction prior to placenta separation.
E) fundal placental implantation.

Question 99

What factor increases the likelihood of a successful external cephalic version.

A) gestational age 34 weeks
B) breech not engaged
C) ruptured membranes
D) anterior placenta

Answer 99

B) breech not engaged

Varney p. 780. ECV should be performed between 36-37 weeks. Factors that decrease the likelihood of success include oligohydramnios, anterior placenta, breech engaged in the pelvis, posterior fetal back, and obesity. ECV is contraindicated after membranes have ruptured.

Question 100

A G1P0 at 41 weeks gestation with an uncomplicated pregnancy has a cervical exam of 1cm/soft/50%/middle/-2 (bishop score 6). She is GBS positive. An appropriate assessment (A) and management plan (P) includes

A) A: late term, unripe cervix; P:strip her membranes, begin fetal surveillance testing.
B) A: late term, ripe cervix; P: schedule an induction of labor with oxytocin.
C) A: late term, unripe cervix; P: shared decision-making for expectant management versus induction
D) A: late term pregnancy, ripe cervix; P:

Answer 100

C) A: late term, unripe cervix; P: shared decision-making for expectant management versus induction

Varney p. 1057. When pregnancy approaches 41 0/7 weeks…principles of shared decision-making can best guide the discussion of care options of expectant management or induction of labor.

Question 101

Diffuse swelling in the infants head is noted shortly after delivery with low forceps . The swelling appears to shift independent of movement. The infant is unresponsive with a thready pulse rate of 180, shallow rapid respiration, and pale, cool skin. What is the likely cause?

A) Subgaleal hemorrhage
B) Caput Succedaneum
C) Intracranial hemorrhage
D) Cephalhematoma

Answer 101

A) Subgaleal hemorrhage

Oxhorn p. 63-64. Varney p. 1318

Question 102

A 11 pound 3 oz baby boy is successfully delivered vaginally after a 3 minute shoulder dystocia. During the newborn’s physical exam the infants left upper arm is noted to have an absent Moro reflex with an intact grasp reflex. The hand is displaying a “waiters tip” sign. The most likely diagnosis is

A) fractured clavical.
B) Klumpke Palsy.
C) Erb’s Palsy.
D) fractured humerous.

Answer 102

C) Erb’s Palsy.

Varney p. 1292: The physical sign of Erb-Duchenne paralysis include generalized loss of movement in the affected arm with an adduction of the lower part of the arm. This leads to the characteristic “waiter’s tip” sign, involving the internal rotation of the lower portion of the arm with the fingers and wrist flexed.”

Question 103

A 26 year-old G1P0 with preeclampsia is induced at 37 weeks gestation. Intrapartum fluid management includes

A) reducing the intravenous fluid bolus prior to an epidural.
B) infusing 1000 ml of crystalloid intravenous fluid to resolve oliguria.
C) limiting total fluid intake (oral and intravenous) to ≤ 200 ml/hour.
D) Monitoring urine output and treating if < 60 ml per hour.

Answer 103

A) reducing the intravenous fluid bolus prior to an epidural.

Question 104

A post-term pregnancy is technically defined as a pregnancy that continues to

A) 41-1/7 (287 days) completed weeks or longer
B) 42-0/7 (287 days) completed weeks or longer
C) 40-1/7 (281 days) completed weeks or longer
D) 42-0/7 (294 days) completed weeks or longer

Answer 104

D) 42-0/7 (294 days) completed weeks or longer

Varney p. 1057. Post-term is the due date plus 2 weeks, or 40 completed weeks plus 2 weeks, or 42 completed weeks. 42 x 7 = 294 days. A completed week is the same thing as a week when discussing gestational age. One completed week = 7 days = one week…40 completed weeks = 280 days = 40 weeks.

Question 105

The attitude of a fetus in a brow presentation is

A) fully flexed.
B) partially extended.
C) neither flexed nor extended.
D) fully extended.

Answer 105

B) partially extended.

Oxhorn p. 67-68 Figure 7-1. Attitude. Varney p. 658 Figure 19-15

Question 106

Which is a major characteristic of disseminated intravascular coagulopathy (DIC)?

A) Hypovolemia
B) Excessive bleeding at sites of minimal trauma
C) Fever
D) Hepatic insufficiency

Answer 106

B) Excessive bleeding at sites of minimal trauma

Question 107

While caring for a HIV positive laboring woman the midwife minimizes the risk of maternal-to-child transmission by

A) infusing antiretroviral medications for viral loads greater than 1000 copies per mL.
B) cutting an episiotomy to hasten delivery.
C) avoiding the use of a fetal scalp electrode.
D) rupturing membranes to decrease the length of labor.

Answer 107

C) avoiding the use of a fetal scalp electrode.

Question 108

To maintain flexion of the head during a breech birth

A) have an assistant apply fundal pressure as the head starts to emerge.
B) apply pressure on the fetal maxilla placing the index and middle fingers on either side of the nose.
C) apply gentle traction just before the buttocks are born.
D) rotate the fetal head to occiput posterior.

Answer 108

B) apply pressure on the fetal maxilla placing the index and middle fingers on either side of the nose.

Question 109

Which of the following is an appropriate hand maneuver during a vaginal breech birth?

A) Ask the nurse to do suprapubic pressure during birth of the head
B) Grasp the baby with your fingers on either side of the umbilicus and your thumbs on either side of the spine in the mid-back
C) Rotate the shoulders to the transverse diameter
D) Downward traction on the legs to assist in descent up to the umbilicus

Answer 109

A) Ask the nurse to do suprapubic pressure during birth of the head

Varney p. 1104 & 1105 Figure 29D-6. The Maurceau-Smellie-Veit maneuver “23. An assistant should be directed to perform suprapubic pressure to maintain flexion of the fetal head.”

Question 110

While discussing the option of vaginal breech delivery with woman whose baby is breech, which of the following pieces of information is most important to include?

A) Strict inclusion criteria and labor management protocols are important for optimal outcomes.
B) When considering the risks of planned vaginal breech birth, it should be compared with planned vaginal cephalic birth.
C) ACOG recommends that all term breech babies be born by cesarean section.
D) Compared with planned cesarean birth for breech presentation, planned vaginal breech birth is associated with an increased risk of serious long term morbidity.

Answer 110

A) Strict inclusion criteria and labor management protocols are important for optimal outcomes.

Varney p. 1084 …specific selection criteria shown to improve success rate such as…efw 2500-4000 grams, frank or complete breech, no fetal anomalies, adequate maternal pelvis, adequate amniotic fluid, and documented flexion of the fetal head on sonogram”

Question 111

A G3 P2002 at 39 weeks arrives for evaluation on the labor unit. While performing Leopold’s maneuvers, you palpate the following: A regular, firm, round, ballotable fetal part in the fundus; a firm, continuously smooth, convex mass extending from the fundus along the front of the maternal left side; an irregular, soft, immovable part above the symphysis pubis; no small fetal parts. Fetal heart tones are heard most easily to the left and slightly above the maternal umbilicus. What is the fetal position?

A) Left sacrum posterior (LSP)
B) Left occiput posterior (LOP)
C) Left sacrum anterior (LSA)
D) Left occiput anterior (LOA)

Answer 111

C) Left sacrum anterior (LSA)

Oxhorn p. 71 Figure 7-4. Position. LSA is left sacrum anterior. Leopold’s suggests a breech presentation: Regular, firm, round fetal part in the fundus suggests this is the fetal head. Irregular, soft, immovable part above the symphysis pubis suggests this is the breech. (The head can be moved as it hinges at the neck while the breech does not move.) Fetal heart tone are generally heard through the fetal back, and if this is occuring above the umbilicus that also suggests a breech presentation. LSA is left sacrum anterior. The sacrum is used as the point of reference for position for breech presentation, as the occiput is for vertex presentation.

Question 112

AMTSL has been shown to:

A) reduce risk of postpartum hemorrhage.
B) result in less overall blood loss.
C) result in less anemia.
D) all of the above.

Answer 112

D) all of the above.

Varney p. 1109-1110. There is abundant research to support all of these benefits of AMTSL. There is also less need for therapeutic uterotonics with AMTSL than when expectant management is used to manage the third stage of labor.

Question 113

According to the current ICM/FIGO AMTSL guidelines, uterine massage is:

A) no longer recommended as a management step in third stage labor.
B) the third step of the recommended three steps of AMTSL, after the placenta is expelled.
C) recommended as a safety measure within one minute of the baby’s birth.
D) only recommended once the cord is clamped and cut in third stage.

Answer 113

B) the third step of the recommended three steps of AMTSL, after the placenta is expelled.

Varney p. 1110 there are 3 components to AMTSL: controlled cord traction, use of a uterotonic, and fundal massage after the placenta is expelled

Question 114

Delayed cord clamping and cutting is compatible with AMTSL because

A) it is associated with health benefits for the neonate
B) it is associated with reduced risk of 3rd stage hemorrhage
C) it is associated with fewer intrauterine infections
D) it is associated with less need for uterotonics in the fourth stage of labor

Answer 114

A) it is associated with health benefits for the neonate

Varney p. 1110. “delayed cord clamping has known positive benefits for the newborn”

Question 115

Which of the following is a symptom of lidocaine toxicity?

A) Hypertension
B) Metallic taste
C) Sweating
D) Swelling of the tongue

Answer 115

B) Metallic taste

Varney p. 1025 Other symptoms of lidocaine toxicity include numbness of the tongue, dizziness, tinnitus, seizures, and, in the worst case, cardiac arrest. The cause of lidocaine toxicity during local anesthetic administration is an accidental injection into the bloodstream.

Question 116

Active management of the third stage of labor (AMTSL), according to the current ICM/FIGO Joint Statement (2003) includes:

A) administration of oxytocin right after the baby is born, controlled cord traction, and uterine massage after the placenta is expelled.
B) administration of oxytocin with delivery of the anterior shoulder, immediate clamping and cutting of the umbilical cord, and controlled cord traction.
C) administration of Cytotec right after the baby is born, controlled cord traction, and uterine massage after the placenta is expelled.
D) administration of oxytocin right after the baby is born, immediate clamping and cutting of the umbilical cord, and controlled cord traction.

Answer 116

A) administration of oxytocin right after the baby is born, controlled cord traction, and uterine massage after the placenta is expelled.

Varney p. 1109-1110 Table 30-2. The three steps of the current evidence-based ICM/FIGO recommendations are: 1. Administration of a uterotonic medication within one minute of the birth of the baby, after ruling out a multiple gestations. Oxytocin is the preferred medication; 2. Controlled cord traction to assist with placental expulsion; and, 3. Uterine massage immediately after placental expulsion, and then as needed. Cytotec is not recommended in settings where oxytocin is available. The available evidence strongly favors oxytocin for its safety and side effect profile. Immediate clamping and cutting of the umbilical cord is no longer recommended. There is adequate evidence to support delayed clamping and cutting of the cord for neonatal/infant benefit without significant risk, and there is no difference in maternal outcomes between immediate and delayed clamping and cutting of the cord.

Question 117

Water intoxication (from hyponatremia) is a potential side effect of what uterotonic?

A) Hemabate
B) Methergine
C) Misoprostol
D) Oxytocin

Answer 117

D) Oxytocin

Varney p. 1067. Oxytocin is chemically very similar to anti-diuretic hormone (ADH), and like ADH can cause water retention. When given in large amounts, especially with non-isotonic IV fluids such as D5W, oxytocin administration can cause water intoxication, a serious complication.

Question 118

Expectant management of third stage labor includes all of the following EXCEPT:

A) watchful waiting.
B) expertise in identifying signs of placental separation.
C) controlled cord traction only with a uterine contraction.
D) spontaneous expulsion of the placenta.

Answer 118

C) controlled cord traction only with a uterine contraction.

Varney p 1110-1111 Table 30-2. Cord traction is not part of expectant management rather a component of AMTSL.

Question 119

Clinical signs of placental separation include

A) a change in the shape of the uterus
B) a decrease in vaginal bleeding
C) displacement of the bladder to the side
D) retraction of the umbilical cord

Answer 119

A) a change in the shape of the uterus

Varney p. 1108 Table 30-1. Clinical signs of placental separation include a sudden trickle or gush of blood, lengthening of the umbilical cord, and change in the shape of the uterus as the uterus contracts.

Question 120

With a velamentous cord insertion, the umbilical cord

A) blood vessels separate and leave the cord prior to the insertion into the surface of the placenta
B) has an abnormal number of blood vessels
C) inserts in the edge of the placenta
D) presents ahead of the fetal presenting part

Answer 120

A) blood vessels separate and leave the cord prior to the insertion into the surface of the placenta

Varney p. 781 velamentous insertion is an abnormality in which the cord inserts into the membranes and not the placental tissue.

Question 121

A laceration involving the vaginal mucosa, posterior fourchette, perineal skin and perineal muscles is of what degree?

A) First
B) Second
C) Third
D) Fourth

Answer 121

B) Second

Varney p. 998 Table 28-10

Question 122

A 40-year-old G5 P5005 delivered a macrosomic infant over an intact perineum after a rapid second stage. Five minutes after the delivery of the placenta, the midwife notices a steady bright red trickle of blood from the woman’s vagina. The uterine fundus is firm, and fundal massage does not affect the amount of bleeding. The midwife should first:

A) inspect the vagina and cervix.
B) administer pain medication appropriate for the postpartum period.
C) administer oxytocin 10 units IM.
D) repeat the fundal check and vital signs in 5 minutes.

Answer 122

A) inspect the vagina and cervix.

Question 123

The first-line uterotonic medication, with evidence of the best effectiveness and side-effect profile, is:

A) Cytotec.
B) Methergine.
C) Pitocin.
D) Hemabate.

Answer 123

C) Pitocin.

Varney p. 1111. ICM/FIGO and WHO recommend oxytocin as the first-choice agent for AMTSL

Question 124

What are the maximum number of doses and closest dosing intervals for administering carboprost tromethamine (Hemabate) to treat immediate postpartum hemorrhage?

A) Eight doses 5 minutes apart.
B) Four doses 5 minutes apart.
C) Eight doses 15 minutes apart.
D) Four doses 15 minutes apart.

Answer 124

C) Eight doses 15 minutes apart.

Varney p. 1121 Table 30-8.

Question 125

What is the correct dosage range for administering Cytotec to treat 4th stage hemorrhage?

A) 600-1000 mcg
B) 400-800 mcg
C) 1000 mcg
D) 200-600 mcg

Answer 125

A) 600-1000 mcg

Varney p. 1121 Table 30-8. 600-800 mcg sublingually; 800- 1,000 mcg per rectum

Question 126

What is the correct dosage for an IM injection of oxytocin (Pitocin)?

A) 10 IU.
B) 20 IU.
C) 30 IU.
D) 40 IU.

Answer 126

A) 10 IU.

Varney p. 1121 Table 30-8

Question 127

The dosage and route for Carboprost tromethamine (Hemabate) administration is:

A) 250 mcg IM.
B) 500 mcg IM.
C) 250 mcg IV.
D) 500 mcg IV.

Answer 127

A) 250 mcg IM.

Varney p. 1121 Table 30-8.

Question 128

Which statement about oxytocin is TRUE :

A) Oxytocin administered by IM injection may cause a hypertensive crisis
B) Oxytocin may be safely administered via IM, IV push, and IV infusion pump.
C) Oxytocin is a “low-risk” medication
D) Oxytocin is a “high alert” medication.

Answer 128

D) Oxytocin is a “high alert” medication.

Varney p. 1066. Oxytocin has many potential adverse fetal and maternal effects and is considered a “high alert” medication. Currently, safe administration practices include standardized IV concentrations, mandatory use of infusion pumps, continuous FHR monitoring, and lower dosing protocols.

Question 129

Which of the following statements regarding the medication misoprostol is true when used during the 4th stage of labor?

A) It can cause severe hypertension if given intravenously.
B) It can cause water intoxication.
C) It is not recommended to treat postpartum hemorrhage
D) It can cause nausea, vomiting, and diarrhea. .

Answer 129

D) It can cause nausea, vomiting, and diarrhea. .

Varney p. 1121 Table 30-8. Misoprostol (Cytotec) can cause GI symptoms. High doses are associated with fever.

Question 130

The dosage and route for Methylergonovine maleate (Methergine) administration is:

A) 2 mg IM.
B) 0.2 mg IM.
C) 2 mg IV.
D) 0.2 mg IV.

Answer 130

B) 0.2 mg IM.

Varney p. 1121 Table 30-8.

Question 131

Which of the following statements regarding the medication oxytocin (Pitocin) is true?

A) Oxytocin can cause severe hypertension if given intravenously.
B) Oxytocin can cause hyponatremia.
C) Oxytocin can cause pyrexia (fever)
D) Oxytocin can cause diarrhea and vomiting.

Answer 131

B) Oxytocin can cause hyponatremia.

Varney p. 1121 Table 30-8

Question 132

Tranexamic acid (Cyklokapron):

A) inhibits fibrinolysis and has a potential risk of thrombosis
B) should not be used if there is a history of cesarean birth
C) has the same side effects as oxytocin (Pitocin)
D) can be administered sublingually

Answer 132

A) inhibits fibrinolysis and has a potential risk of thrombosis

Varney p. 1121 Table 30-8

Question 133

Which of the following statements regarding ergot alkaloids such as methergine is true?

A) They should be administered IV push
B) They cannot be given to women with a history of asthma
C) They cause a sustained uterine contraction
D) They may cause a transient fall in blood pressure

Answer 133

C) They cause a sustained uterine contraction

Question 134

A G1P0 at 41 weeks gestation is receiving oxytocin augmentation for slow labor progress. Of the several accepted dosing regimens for the use of oxytocin for augmentation, the midwife chooses a regimen in which the dosage of the oxytocin is increased about every thirty minutes. What is the rationale for that specific timeframe for increases?

A) Because “high dose” regimens should never be used.
B) The interval required to reach a steady state of oxytocin in the bloodstream is thirty to forty minutes.
C) This regimen enables the provider to reach the dose of oxytocin required for successful augmentation quickly.
D) Women requiring augmentation usually require high doses of oxytocin to attain an effective contraction pattern.

Answer 134

B) The interval required to reach a steady state of oxytocin in the bloodstream is thirty to forty minutes.

Varney p. 1067

Question 135

The goal of magnesium sulfate (MgSO4) in women with preeclampsia is to

A) improve urine output.
B) prevent convulsions.
C) reduce blood pressure.
D) prevent hemolysis.

Answer 135

B) prevent convulsions.

Question 136

A G3 P2 is Covid positive and in active labor has severe back pain during contractions. During a vaginal exam you palpate the anterior fontanel in the anterior portion of the pelvis. Which of the following is the best option for optimal fetal positioning?

A) Hands and knees position
B) Sterile water papules
C) Administration of epidural anesthesia to relax the pelvic floor
D) Lithotomy position

Answer 136

A) Hands and knees position

Question 137

The clinician is treating a 38 year old woman for fatigue and heavy menstrual bleeding. The patient’s hemoglobin is 8 and the hematocrit is 25.6. The clinician is most likely to diagnose iron-deficiency anemia from which of the following tests?

A) Increased mean corpuscular volume
B) Decreased total iron binding capacity (TIBC)
C) Decreased serum ferritin
D) Hemoglobin electrophoresis

Answer 137

C) Decreased serum ferritin

Question 138

What structures are involved in a 2nd degree vaginal laceration?

A) the clitoris or periurethral tissue
B) vaginal mucosa, vaginal fascia, the bulbocavernosus muscle, and the internal anal sphincter
C) vaginal mucosa, vaginal fascia, the bulbocavernosus muscle, and subcutaneous tissue
D) vaginal mucosa, vaginal fascia, the bulbocavernosus muscle, and the external anal sphincter

Answer 138

C) vaginal mucosa, vaginal fascia, the bulbocavernosus muscle, and subcutaneous tissue

Question 139

Asymptomatic clients with thalassemia most likely have

A) Cooley’s anemia
B) thalassemia intermedia
C) thalassemia major
D) thalassemia minor

Answer 139

D) thalassemia minor

Question 140

Which of the following is NOT associated with fetal bradycardia?

A) Chorioamnionitis
B) Congenital heart block
C) Fetal compromise
D) Uterine rupture

Answer 140

A) Chorioamnionitis

Varney p. 923. Tachycardia is associated with chorio.

Question 141

The definition of prelabor rupture of membranes (PROM) is

A) rupture of membranes more than one hour prior to the onset of labor.
B) rupture of membranes prior to the onset of labor.
C) rupture of membranes prior to 37 weeks gestation.
D) rupture of membranes more than 12 hours prior to the onset of labor.

Answer 141

B) rupture of membranes prior to the onset of labor.

Question 142

Which of the following may decrease the number of cesarean births for slow labor progress?

A) Correct diagnosis of active labor
B) Early amniotomy
C) Early oxytocin augmention
D) More liberal use of epidural anesthesia for pain control

Answer 142

A) Correct diagnosis of active labor

Varney p.887 “Accurately diagnosing active labor is of the utmost importance because it serves as the basis against which labor progress (and) the need for intervention is determined.” The 2014 SMFM/ACOG position statement Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. also states the accurate diagnosis of active labor non-intervention in early labor are best practices to prevent primary cesarean.

Question 143

Engagement is defined as descent of the biparietal diameter of the fetal head to a level at or below the:

A) Ischial spines
B) Pelvic inlet
C) Pelvic outlet
D) Sacral promontory

Answer 143

B) Pelvic inlet

Varney p. 869 “when the fetus is at 0 station, the biparietal diameter is most always descended through the inlet and is, thus, engaged.”

Question 144

You are caring for a G1 P0 in active labor at 7 cm. The fetal monitor is on for a 20 minute tracing, and you observe a fetal heart rate in the 90’s, which begins with a contraction and lasts for 7 minutes. This should be described as:

A) An early deceleration
B) A prolonged deceleration
C) A variable deceleration
D) Bradycardia

Answer 144

B) A prolonged deceleration

Varney p. 928

Question 145

A relatively small pelvic inlet may result in:

A) Deep transverse arrest
B) Major perineal lacerations
C) Posterior position
D) Significant asynclitism

Answer 145

D) Significant asynclitism

Varney p. 869 synclitism is the orientation of the fetal sagittal suture in the same line as the pelvic inlet….anterior asynclitism facilitates the mechanism of descent.”

Oxhorn p. 85 “whenever there is a small pelvis or a large head, asynclitism plays an important part in enabling engagement.”

Question 146

Birth of the head in the direct occiput posterior position occurs via which cardinal movement(s)?

A) Extension followed by flexion
B) Flexion followed by extension
C) Long arc rotation
D) Short arc rotation

Answer 146

B) Flexion followed by extension

Varney p. 874 step 5.

Question 147

When the fetal head is in the OP position, what are the findings on vaginal exam?

A) The anterior fontanel is palpable by the symphysis pubis
B) The posterior fontanel is palpable by the symphysis pubis
C) The fontanels are in the fundus
D) The fontanels are not palpable

Answer 147

A) The anterior fontanel is palpable by the symphysis pubis

Varney p. 658 figure 19-16

Question 148

In active labor the fetal heart rate should be auscultated

A) Continuously
B) Every fifteen minutes
C) Every five minutes
D) Every sixty minutes

Answer 148

B) Every fifteen minutes

Varney p. 944 “ACNM recommends IA every 15-30 minutes during active labor”.

Question 149

Which of the following suggests a fetus in a posterior position?

A) Anterior asynclitism
B) Cephalic prominence is found on the same side as the fetal back
C) Fundal height is less than anticipated for gestational age
D) Small parts (arms and legs) easily palpated in the front of the woman’s abdomen during Leopold’s maneuvers

Answer 149

D) Small parts (arms and legs) easily palpated in the front of the woman’s abdomen during Leopold’s maneuvers

Varney p. 745 “fetal small parts should be opposite the fetal back”

Question 150

Compared with lose dose oxytocin regimens, high dose regimens are associated with

A) a higher rate of cesarean births
B) less prostagladin use
C) longer labor
D) more uterine tachysystole

Answer 150

D) more uterine tachysystole

Varney p. 1067 “High-dose (synthetic oxytocin) regimens are associated with more uterine tachysystole”.

Question 151

The biparietal diameter of the fetal head:

A) Is the largest anteroposterior diameter
B) Is the largest transverse diameter
C) Presents when the fetus is in the military attitude
D) Runs from the forehead to the chin

Answer 151

B) Is the largest transverse diameter

Oxhorn p. 58 Figure 6-2.

Question 152

Which of the following describes a fetal lie?

A) Breech
B) Cephalic
C) Oblique
D) Posterior

Answer 152

C) Oblique

Oxhorn p. 66

Question 153

Caput succedaneum:

A) Is a hemorrhage under the periosteum of a bone of the skull
B) Is an indication of probable cephalo-pelvic disproportion
C) Is caused by a forceps delivery
D) May interfere with an accurate assessment of fetal station

Answer 153

D) May interfere with an accurate assessment of fetal station

Varney p. 871 “it is important to make sure station is determined based on the level of the fetal skull bone and not based on caput.”

Question 154

The anterior and posterior fontanels are identified during labor in order to:

A) Assess the adequacy of the pelvic inlet
B) Assess for dehydration
C) Determine fetal head position
D) Determine fetal lie

Answer 154

C) Determine fetal head position

Oxhorn p. 56-57

Question 155

You are caring for a G2P1001 at term with an uncomplicated prenatal and first stage of labor, with a reassuring fetal heart rate pattern throughout. She has been completely dilated and pushing for 20 minutes and second stage is progressing quickly. You expect birth in the next few minutes. The following fetal heart rate pattern is noted: Baseline 140’s, moderate FHR variability, no decelerations initially with pushing but abrupt decelerations down to 100’s lasting 20-30 seconds with the last 2 contractions. What is the most appropriate management?

A) Await spontaneous birth
B) Cesarean section
C) IV fluids, oxygen and position changes
D) Vacuum assisted birth

Answer 155

A) Await spontaneous birth

Varney p. 927-928. Variable decelerations are the most common variant FHR seen in half or more of all labors. Variable decelerations happen secondary to interruption of umbilical cord blood flow and are very common in the second stage of labor. In the presence of moderate FHR variability and imminent birth, the best course of action is to wait for birth to take place and the cord compression to be resolved.

Question 156

The presentation of the fetus refers to the:

A) Location of the fetal fontanels in relationship to the maternal pelvis
B) Part of the fetus that is entering the pelvic inlet first
C) Relationship of the long axis of the fetus relative to the mother
D) Relationship of the denominator to the front, back or sides of the maternal pelvis

Answer 156

B) Part of the fetus that is entering the pelvic inlet first

Oxhorn p. 66

Question 157

A G1P0 at term with an unremarkable medical and prenatal history comes to the hospital for a labor evaluation. She has been contracting every 5-20 minutes for 6 hours. Vaginal exam results are 1 cm/25% effaced/-2 station. Your teaching should include which information?

A) Admission to the hospital before active labor is associated with a higher rate of intervention.
B) CPD is a concern because the head is not engaged.
C) If this is false labor, the contractions will slow or stop with walking.
D) The location of the contractions is helpful in determining phase of labor.

Answer 157

A) Admission to the hospital before active labor is associated with a higher rate of intervention.

Varney p. 892. Admission prior to active labor is associated with increased oxytocin augmentation and cesarean birth.

Question 158

A G2 P1 at 40 weeks is admitted with contractions every 2-4 minutes and a cervical exam of 6 cm/90%/-2 station. Two hours later her contraction pattern is unchanged and her cervical exam is 8 cm/100%/-1 station. According to Friedman criteria, this labor progress is:

A) Arrested
B) Normal
C) Prodromal
D) Protracted

Answer 158

D) Protracted

Varney p. 887 according to Friedman, the slowest acceptable rate of cervical change for a multipara in active labor is 1.5 cm per hour. According to this standard, 2 cm of cervical change in 2 hours is less than expected and thus labor has become protracted.

Question 159

Extension of the fetal head occurs so that that the

A) Head can pivot under the symphysis pubis
B) Head can rotate 180 degrees
C) Long axis of the fetal head can align with the long access of the pelvic inlet
D) Smallest diameter of the head presents at the pelvic inlet

Answer 159

A) Head can pivot under the symphysis pubis

Varney p. 874 step 5

Question 160

A G1P0 at 40 weeks is in active labor. At noon her cervical exam is 6 cm/100% effaced/0 station. At 3 pm her cervical exam is 8 cm/100% effaced/0 station. According to contemporary criteria her labor progress is

A) arrested
B) dysfunctional
C) normal
D) prolonged

Answer 160

C) normal

Varney p. 888 Zhang, et al., describe the rate of cervical change between 6 and 8 centimeters varied from 0.5 to 0.8 cm and never exceeded 1.0 cm. According to the criteria, 2cm cervical change in 3 hours falls within the slowest yet normal expected rate of change (0.5 cm/hr).

Question 161

The risk of hyperstimulation with misoprostol is related to the

A) dosage used
B) gestational age
C) indication for use
D) parity of the woman

Answer 161

A) dosage used

Varney p. 1065 Table 29-7. Misoprostol dose is 25-50 mcg orally or 25 mcg vaginally, “vaginal doses of 50mcg are associated with higher incidence of uterine tachysystole and are not recommended”

Question 162

A G2 P1 is on the maternity unit for a labor evaluation. She is having occasional contractions and states she had a gush of fluid just before leaving home. In this situation, the nitrazine paper test to assess for ruptured membranes

A) Can not be used until active labor
B) Is the most accurate method to make this determination
C) Will determine the specific gravity of the fluid
D) Will show false positive if exposed to blood or cervical mucus

Answer 162

D) Will show false positive if exposed to blood or cervical mucus

Verney p. 910: the nitrazine test: “false positive results can occur in the presence of vaginal infections, blood, semen or other alkaline substances.”

Question 163

In which area of the fetal head is the occiput?

A) Back
B) Front
C) Side
D) Top

Answer 163

A) Back

Oxhorn p. 58 figure 6-2.

Question 164

A 17 year old G1 P0 at 40 weeks gestation is admitted to the maternity unit at 3 pm in active labor at 6 cm dilation. At 5 pm she is 7 cm dilated. Four hours later there is no change in cervical dilation. Which is the most appropriate management plan?

A) Cesarean birth
B) Oxytocin augmentation
C) Prostagladins for cervical ripening
D) Therapeutic rest

Answer 164

B) Oxytocin augmentation

Even though the Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery doesn’t set forth a specific time when oxytocin augmentation should be considered, our understanding of the slowest yet normal rate of cervical change in a primigravida > 6cm dilated is 0.3 cm per hour on average. Even at this very slow rate, a detectable change in dilation should be appreciated after 4 hours. Initiating oxytocin augmentation after 4 hours of no change is reasonable. Further, the Obstetric Care Consensus No. 1: Safe Prevention of the Primary Cesarean Delivery suggests that cesarean could be considered after 8 hours of oxytocin augmentation with adequate contractions (p. 7). Cervical ripening and therapeutic rest are not interventions used ina active labor. Cervical ripening is part of labor induction and therapeutic rest is a modality used in early labor to treat exhaustion.

Question 165

When compared to hospital birth, home birth is associated with a

A) higher rate of interventions
B) higher perinatal mortality rate
C) lower perinatal mortality rate
D) lower rate of interventions

Answer 165

D) lower rate of interventions

Varney p. 1145 “obstetric interventions and cesarean birth are lower for women who begin their labors planning to give birth in an out-of-hospital setting”.

Question 166

A 31 year old G1P0 at 39 weeks is seeing you for a prenatal visit. She is tired of being pregnant and requests an elective induction. Your teaching should include which of the following:

A) Elective induction may increase her risk of cesarean section.
B) Elective induction at 39 weeks is associated with improved fetal outcomes.
C) If she waits until she is 40 weeks, elective induction is not associated with an increased risk of cesarean section
D) You can do an elective induction if your consultant agrees.

Answer 166

A) Elective induction may increase her risk of cesarean section.

Varney page 1062. “…risk of cesarean section is substantially increased for nulliparous women.”

Question 167

Long arc rotation describes rotation of the fetal head:

A) 45 degrees to the occiput posterior position
B) 135 degrees to an occiput anterior position
C) From a position of posterior asynclitism to synclitism
D) To a cephalic presentation

Answer 167

B) 135 degrees to an occiput anterior position

Varney p. 873 step 4

Question 168

An amplitude range of greater than 25 beats per minute should be characterized as:

A) Marked
B) Minimal
C) Moderate
D) Reassuring

Answer 168

A) Marked

Varney p. 915 Table 26-1

Question 169

You see a G2P1 at 38 weeks in the hospital for a labor evaluation at noon. Vitals signs are normal and the fetal heart rate tracing is noted to be category 1. Contractions started at 1 am and are now every 2-4 minutes, 60-70 seconds long, moderate-strong by palpation and subjective report. Vaginal exam results: 5 cm/100%/0 station. Which is the best management plan?

A) Admit for labor
B) Amniotomy
C) Encourage her to go home to await more active labor
D) Therapeutic rest for prolonged latent phase

Answer 169

A) Admit for labor

Varney p. 889 “cervical change progressively accelerates with each passing centimeter”. The median rate of cervical change from 5 to 6 cm for a person with a parity of 1 is 0.8 cm/hr (Table 25-3). The end of latent phase is imminent and admission for active labor is clinically indicated.

Question 170

The consensus of the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop on electronic fetal heart rate monitoring regarding variability is:

A) Assessment of short term variability is necessary in order to determine fetal status
B) No distinction is made between short and long term variability
C) Assessment of variability is not important in determining fetal status
D) Variability can only be determined with a scalp electrode (internal FHR monitoring)

Answer 170

B) No distinction is made between short and long term variability

Question 171

Defining arrested labor as no progress for two hours in active labor:

A) Decreases cesarean section rates
B) Decreases rates of oxytocin augmentation for labor dystocia
C) Improves neonatal outcomes
D) May be challenged based on contemporary research

Answer 171

D) May be challenged based on contemporary research

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. p 5-6. Contemporary research demonstrates that active labor begins at later in labor than Friedman suggested and the rate of dilation is slower. “Because they are contemporary and robust, it seems that the Consortium on Safe Labor data, rather than the standards proposed by Friedman, should inform evidence-based labor management.”

Question 172

Variable decelerations:

A) Begin after the onset of a contraction
B) Begin with the onset of the contraction
C) Have a gradual onset
D) Have an abrupt onset

Answer 172

D) Have an abrupt onset

Varney p. 927 figure 26-8

Question 173

Which of the following is the cardinal movement of labor that will allow the fetus to align the AP diameter of the fetal head with the longest diameter of the mid-pelvis?

A) Extension
B) External rotation
C) Internal rotation
D) Restitution

Answer 173

C) Internal rotation

Varney p. 873 step 4

Question 174

If the attitude of the fetal head is fully extended, what is the type of cephalic presentation?

A) Brow
B) Face
C) Military
D) Vertex

Answer 174

B) Face

Varney p. 658 figure 19-15 (d.) Oxhorn p. 73 figure 7-5.

Question 175

Contemporary research on diagnosing and managing slow labor

A) clarifies when interventions are needed
B) clarifies when slow labor is associated with perinatal complications
C) does not provide clear recommendations for appropriate timing of interventions
D) shows that commonly used protocols do not recommend intervening soon enough

Answer 175

C) does not provide clear recommendations for appropriate timing of interventions

Varney p. 1070-1071 describes the process for assessment of slow labor and possible interventions but does not describe the timing of interventions.

Question 176

You are caring for a G3 P2 with pre-eclampsia and suspected IUGR. Based on ACOG recommendations, how often should the EFM tracing be reviewed during the second stage of labor?

A) At least every five minutes
B) At least every fifteen minutes
C) At least every ten minutes
D) Continuously

Answer 176

A) At least every five minutes

Varney p. 944

Question 177

A G1P0 at term calls you to discuss possible labor. She began having contractions 3 hours ago and they are now every 8-10 minutes. She is experiencing some nausea. Which is the best management plan?

A) Admit for intravenous fluids
B) Advise her continue to sip fluids and eat easily digestible foods
C) Advise her stop eating and drinking
D) Give P.O. Vistaril® (hydroxyzine) to control the nausea

Answer 177

B) Advise her continue to sip fluids and eat easily digestible foods

Varney p. 876 “hypoglycemia due to fasting can lead to…accumulation of lactate and ketones…consumption of a light diet (is) not associated with adverse outcomes”.

Question 178

A G3 P2 at 38 weeks with an uncomplicated pregnancy comes to the OB unit for evaluation, her third time in one week. She is not bleeding or leaking fluid. Her contractions are mild and irregular. Vital signs are normal, fetal heart rate assessment shoes category one tracing. Cervical exam is 3cm/thick/-1 station. Which of the following would you recommend?

A) Artificial rupture of membranes
B) Cesarean section
C) Go home to await active labor
D) Stimulation of labor with oxytocin

Answer 178

C) Go home to await active labor

Varney p. 892 admission prior to active labor is associated with increased oxytocin augmentation and cesarean birth

Question 179

Compared to Friedman’s research in the 1950’s and 60’s, contemporary research has shown average labor duration to be:

A) Dependent on type of care provider
B) Longer
C) Shorter
D) The same

Answer 179

B) Longer

Varney p. 887-888 states contemporary research indicates that, for many reasons, normal labor is longer than what was described by Friendman in the 1950’s. Zhang et al., found the median length of labor to be 2 hours greater for multiparous women and 2.6 hours greater in nulliparous women.

Question 180

A 17 year old G3 P0020 at 40 3/7 weeks gestation began having contractions every 10 to 20 minutes around 2 am. She is admitted to the hospital OB unit at 3 pm at which time her contractions are every 4 to 6 minutes and her cervical exam is 2 centimeters dilated, 75% effaced and the head is at -1 station. Four hours later her contractions are every 3-4 minutes and she is 7 centimeters dilated, 90% effaced with the head at -1 station Two hours later there is no change in either her contraction pattern or her cervical exam. Using Friedman criteria, which of the following describes her labor progress?

A) Normal progress
B) Prolonged latent phase
C) Secondary arrest of dilatation
D) Protracted active phase

Answer 180

C) Secondary arrest of dilatation

First Stage, Latent phase (note that latent phase is calculated based on total duration, not rate of dilation per hour):

Nulliparas: <20 hours

Multiparas: <14 hours

First Stage, Active phase:

Nulliparas: At least 1.2 cm/hr dilatation

Multiparas: At least 1.5 cm/hr dilatation

Second Stage

Nulliparas: 1 cm/hr descent

Multiparas: 2 cm/hr descent

Source: NM 704 Module 4 lecture

Question 181

Restitution occurs as a result of the:

A) Internal rotation of the shoulders
B) Release of extension after birth
C) Rotation from a posterior to an anterior position
D) Untwisting of the neck after birth

Answer 181

D) Untwisting of the neck after birth

Varney p. 874 step 6