Certified Midwife Exam Prep Case Studies & Practical Application 3 — Questions and Answers
Question 1: A client at 34 weeks presents with painless bright red vaginal bleeding. She denies contractions and fetal heart tones are 145 bpm. What is the most likely diagnosis and first action?
- Placenta previa; perform ultrasound before any vaginal examination (Correct answer)
- Placental abruption; perform immediate vaginal exam to assess cervix
- Bloody show; reassure and monitor for labor
- Vasa previa; allow spontaneous labor to proceed
Correct answer: Placenta previa; perform ultrasound before any vaginal examination
Painless bright red bleeding at 34 weeks suggests placenta previa; digital vaginal exam is contraindicated until placental location is confirmed by ultrasound.
Question 2: During second-stage labor a fetal heart rate tracing shows a prolonged deceleration to 70 bpm for 3 minutes. Cervix is 10 cm and the vertex is at +2 station. What is the priority action?
- Reposition the client, apply oxygen, and prepare for operative delivery (Correct answer)
- Continue monitoring and wait for spontaneous recovery of FHR
- Start oxytocin to accelerate delivery
- Perform an amnioinfusion immediately
Correct answer: Reposition the client, apply oxygen, and prepare for operative delivery
A prolonged deceleration with a vertex at +2 station at full dilation requires urgent resuscitative measures and preparation for assisted or operative delivery.
Question 3: A 26-year-old at 10 weeks gestation reports nausea, vomiting, a uterus larger than expected, and a beta-hCG of 280,000 mIU/mL. Ultrasound shows a snowstorm pattern. What is the management?
- Suction curettage followed by serial beta-hCG monitoring (Correct answer)
- Expectant management with repeat ultrasound in 2 weeks
- Immediate chemotherapy with methotrexate
- Schedule cesarean delivery at 37 weeks
Correct answer: Suction curettage followed by serial beta-hCG monitoring
A snowstorm pattern on ultrasound with markedly elevated beta-hCG is diagnostic of a complete hydatidiform mole requiring suction evacuation and surveillance.
Question 4: A client delivers a 4,400 g infant and has an estimated blood loss of 600 mL. Uterus is boggy after oxytocin administration and massage. What is the next pharmacological option?
- Methylergonovine (Methergine) IM if no hypertension is present (Correct answer)
- Repeat oxytocin bolus IV
- Magnesium sulfate IV infusion
- Carboprost regardless of asthma history
Correct answer: Methylergonovine (Methergine) IM if no hypertension is present
Methylergonovine is the next uterotonic after oxytocin failure if the client has no hypertension, acting on uterine smooth muscle to enhance tone.
Question 5: A newborn at 2 hours of life has a blood glucose of 38 mg/dL, jitteriness, and poor feeding. The infant was born at 39 weeks to a mother with gestational diabetes. What is the priority intervention?
- Initiate a glucose gel protocol and attempt breastfeeding (Correct answer)
- Perform a heel stick recheck in 30 minutes without intervention
- Administer IV dextrose immediately without attempting feeding
- Transfer to NICU and begin total parenteral nutrition
Correct answer: Initiate a glucose gel protocol and attempt breastfeeding
Symptomatic neonatal hypoglycemia in an IDM is managed first with glucose gel and breastfeeding before escalating to IV glucose if unresponsive.
Question 6: A 38-year-old at 20 weeks has a quad screen with a low AFP, low estriol, elevated hCG, and elevated inhibin A. What condition does this pattern suggest?
- Trisomy 21 (Down syndrome) (Correct answer)
- Trisomy 18 (Edwards syndrome)
- Neural tube defect
- Turner syndrome
Correct answer: Trisomy 21 (Down syndrome)
The quad screen pattern of low AFP, low estriol, elevated hCG, and elevated inhibin A is the classic finding associated with Down syndrome.
Question 7: A client at 28 weeks with a history of preterm birth presents with pelvic pressure and 4 contractions per hour. Cervical length on transvaginal ultrasound is 20 mm. What is an evidence-based intervention?
- Administer betamethasone and consider 17-OHPC or cerclage based on history (Correct answer)
- Bedrest and pelvic rest without medications
- Immediate induction due to preterm labor risk
- Perform amniocentesis to rule out infection before any treatment
Correct answer: Administer betamethasone and consider 17-OHPC or cerclage based on history
Betamethasone promotes fetal lung maturity and is indicated between 24-34 weeks; progesterone and cerclage are evidence-based for preterm birth prevention in high-risk pregnancies.
Certified Midwife Exam Prep Case Studies & Practical Application 3
A client at 34 weeks presents with painless bright red vaginal bleeding.
She denies contractions and fetal heart tones are 145 bpm.
What is the most likely diagnosis and first action?