Certified Midwife Exam Prep Case Studies & Practical Application 5 — Questions and Answers
Question 1: A client at 32 weeks with twin gestation develops sudden onset dyspnea, cough, and hypoxia. She has no fever or productive cough. Vital signs show HR 122 and SpO2 88% on room air. What is the priority diagnosis to rule out?
- Pulmonary embolism (Correct answer)
- Pneumonia
- Asthma exacerbation
- Preterm labor with cord prolapse
Correct answer: Pulmonary embolism
Twin pregnancy significantly increases the risk of venous thromboembolism; sudden dyspnea and hypoxia without fever must prompt urgent workup for pulmonary embolism.
Question 2: A laboring client at 7 cm with ruptured membranes suddenly reports a gush of fluid. On sterile vaginal exam the midwife palpates a pulsating cord at the introitus. What is the immediate action?
- Elevate the presenting part manually, call for emergency cesarean, and maintain upward pressure until delivery (Correct answer)
- Place the client in Trendelenburg and push the cord back into the uterus
- Apply direct traction on the cord to accelerate delivery
- Administer tocolytics and transfer via ambulance to the hospital
Correct answer: Elevate the presenting part manually, call for emergency cesarean, and maintain upward pressure until delivery
Cord prolapse requires immediate manual elevation of the presenting part to relieve compression while preparing for emergency cesarean delivery.
Question 3: A client at 22 weeks has a uterus at 28-week size, severe nausea, and hyperemesis. Ultrasound shows bilateral ovarian cysts with a 'ground glass' appearance and no fetal heartbeat. What is the most likely diagnosis?
- Complete hydatidiform mole with theca lutein cysts (Correct answer)
- Dichorionic-diamniotic twin pregnancy
- Ovarian hyperstimulation syndrome
- Fibroid uterus with coexistent pregnancy
Correct answer: Complete hydatidiform mole with theca lutein cysts
Bilateral theca lutein cysts arise from hCG overstimulation and are classic findings associated with complete hydatidiform mole.
Question 4: A 29-year-old at 38 weeks has been pushing for 2.5 hours. The fetal head is at +3 station, occiput anterior, and the FHR tracing shows late decelerations with decreased variability. What is the next step?
- Prepare for operative vaginal delivery or emergent cesarean based on provider capability (Correct answer)
- Encourage the client to push harder and continue monitoring
- Administer a maternal fluid bolus and reposition to left lateral
- Perform amnioinfusion to correct the late decelerations
Correct answer: Prepare for operative vaginal delivery or emergent cesarean based on provider capability
Recurrent late decelerations with decreased variability at +3 station after prolonged pushing indicate fetal compromise requiring delivery by the most expedient route.
Question 5: A postpartum client at day 7 calls reporting a red, warm, swollen right calf and difficulty walking. She had a cesarean delivery and is not yet ambulating well. What is the priority action?
- Refer immediately to an emergency department for DVT workup and possible anticoagulation (Correct answer)
- Recommend leg elevation and ice packs and recheck in 48 hours
- Prescribe NSAIDs and schedule a Doppler ultrasound electively
- Advise increased ambulation and reassess at her 2-week visit
Correct answer: Refer immediately to an emergency department for DVT workup and possible anticoagulation
Unilateral calf swelling, warmth, and erythema in a postoperative patient are classic signs of deep vein thrombosis requiring urgent diagnosis and anticoagulation.
Question 6: A client at 24 weeks with no prenatal care is found to have a BP of 154/98 and proteinuria on dipstick. She reports headache and blurry vision. What distinguishes this from chronic hypertension?
- The presence of proteinuria, neurologic symptoms, and onset after 20 weeks suggests new-onset preeclampsia (Correct answer)
- Chronic hypertension always presents with proteinuria making differentiation impossible
- BP of 154/98 is normal in mid-pregnancy and requires no further workup
- Preeclampsia cannot be diagnosed before 28 weeks gestation
Correct answer: The presence of proteinuria, neurologic symptoms, and onset after 20 weeks suggests new-onset preeclampsia
Preeclampsia is distinguished from chronic hypertension by new-onset proteinuria and end-organ symptoms after 20 weeks, though the distinction is complex without prior BP records.
Question 7: A 34-year-old at 36 weeks with obstetric cholestasis has pruritis and total bile acids of 42 µmol/L. Liver enzymes are mildly elevated. What is the evidence-based management?
- Administer ursodeoxycholic acid and plan delivery at 36-37 weeks (Correct answer)
- Expectant management until 40 weeks with weekly bile acid monitoring
- Perform immediate delivery regardless of gestational age
- Treat with antihistamines only and reassess in 2 weeks
Correct answer: Administer ursodeoxycholic acid and plan delivery at 36-37 weeks
Ursodeoxycholic acid reduces maternal symptoms and bile acid levels; delivery at 36-37 weeks balances the risk of stillbirth against prematurity in intrahepatic cholestasis of pregnancy.
Certified Midwife Exam Prep Case Studies & Practical Application 5
A client at 32 weeks with twin gestation develops sudden onset dyspnea, cough, and hypoxia.
She has no fever or productive cough.
Vital signs show HR 122 and SpO2 88% on room air.
What is the priority diagnosis to rule out?