NARM Certified Professional Midwife (CPM) Exam — Questions and Answers

Question 1: A midwife learns that a colleague is practicing outside her approved scope by routinely performing vacuum-assisted deliveries at home births. The midwife should:

Assume the colleague has special training and take no action
Share the information only with mutual clients who ask
Report the concern through appropriate professional or regulatory channels to protect client safety (Correct answer)
Confront the colleague publicly at the next professional meeting

Correct answer: Report the concern through appropriate professional or regulatory channels to protect client safety

Peer accountability requires that unsafe or out-of-scope practice be reported through appropriate channels—this is an ethical obligation to protect clients.

Question 2: When a midwife identifies a situation beyond her scope of practice during labor, the most appropriate action is to:

Initiate emergency transport and consult or transfer care to an appropriate provider (Correct answer)
Continue managing the situation to avoid alarming the client
Document the situation and address it during the postpartum visit
Proceed cautiously while contacting a backup provider for telephone guidance

Correct answer: Initiate emergency transport and consult or transfer care to an appropriate provider

When a situation exceeds the midwife's scope, immediate consultation, collaboration, or transfer to an appropriate provider is the professional and ethical obligation.

Question 3: A client has a penicillin allergy documented as 'anaphylaxis.' Which antibiotic should be used for GBS prophylaxis after confirming susceptibility?

Cefazolin 2 g IV then 1 g q8h
Clindamycin 900 mg IV q8h (Correct answer)
Amoxicillin 500 mg PO q8h
Vancomycin 20 mg/kg IV q8h

Correct answer: Clindamycin 900 mg IV q8h

For clients with high-risk penicillin allergy (anaphylaxis, angioedema, urticaria), clindamycin is used if the GBS isolate is susceptible; cefazolin is used only for low-risk penicillin allergy.

Question 4: Under the NARM Certified Professional Midwife (CPM) credential framework, which body is responsible for establishing the standards of competency that CPMs must demonstrate?

The Midwives Alliance of North America (MANA)
The state licensing board in each jurisdiction
The North American Registry of Midwives (NARM) (Correct answer)
The American College of Nurse-Midwives (ACNM)

Correct answer: The North American Registry of Midwives (NARM)

NARM is the certifying body that establishes the competency standards and administers the NARM Written Exam and Skills Assessment for the CPM credential.

Question 5: Which documentation element is most critical after every prenatal visit according to professional midwifery standards?

A legible, contemporaneous record including findings, discussions, client questions, and the plan of care (Correct answer)
A billing invoice with procedure codes
A standardized hospital-style progress note regardless of birth setting
A signed waiver from the client for each visit

Correct answer: A legible, contemporaneous record including findings, discussions, client questions, and the plan of care

Contemporaneous, legible documentation that captures findings, counseling, client questions, and the care plan is the standard for all prenatal encounters.

Question 6: Signs of neonatal jaundice?

Excessive crying
Blue skin
Red rash
Yellow skin and eyes from elevated bilirubin (Correct answer)

Correct answer: Yellow skin and eyes from elevated bilirubin

This condition causes characteristic color changes.

Question 7: A midwife's client at 41+3 weeks declines membrane sweeping and asks about expectant management beyond 42 weeks. The most appropriate midwifery response is:

Agree to expectant management without any additional monitoring
Perform membrane sweeping without consent to protect the fetus
Provide detailed counseling on increased risks of post-term pregnancy, recommend consultation, and discuss enhanced surveillance options (Correct answer)
Discontinue care since home birth at 42+ weeks is universally outside CPM scope

Correct answer: Provide detailed counseling on increased risks of post-term pregnancy, recommend consultation, and discuss enhanced surveillance options

Post-term pregnancy carries increased fetal risks; the midwife must counsel thoroughly, offer consultation, and discuss monitoring options while respecting client autonomy.

Question 8: Umbilical cord care for newborns?

Cover with bandages
Submerge in water
Apply alcohol daily
Keep clean and dry until natural detachment in 1-3 weeks (Correct answer)

Correct answer: Keep clean and dry until natural detachment in 1-3 weeks

Current evidence supports simple dry care.

Question 9: A client develops signs of local anesthetic toxicity after a pudendal block, including perioral numbness, ringing in the ears, and confusion. What is the most serious complication to anticipate?

Cardiovascular collapse and seizures (Correct answer)
Uterine atony
Allergic anaphylaxis
Neonatal respiratory depression

Correct answer: Cardiovascular collapse and seizures

Local anesthetic systemic toxicity (LAST) can rapidly progress from CNS prodromal symptoms to cardiovascular collapse and refractory ventricular arrhythmias.

Question 10: Which document is crucial for ensuring that a midwife's professional and ethical responsibilities are clearly defined?

The midwife’s curriculum vitae
The midwife’s personal journal
The midwifery care plan for each client
The state or national midwifery practice guidelines and scope of practice (Correct answer)

Correct answer: The state or national midwifery practice guidelines and scope of practice

State or national midwifery practice guidelines and the defined scope of practice are crucial documents because they legally and professionally delineate what a midwife is authorized and expected to do. These guidelines ensure consistent, safe, and ethical care by outlining the boundaries of practice, required competencies, and professional responsibilities. They serve as the foundational framework for a midwife's professional conduct and accountability.

Question 11: What is the primary purpose of conducting a non-stress test (NST) in the third trimester of pregnancy?

To measure the size of the fetal head
To determine the mother’s blood glucose levels
To assess fetal lung maturity
To evaluate fetal heart rate patterns in response to fetal movements (Correct answer)

Correct answer: To evaluate fetal heart rate patterns in response to fetal movements

A non-stress test (NST) monitors the fetal heart rate (FHR) and its accelerations in response to fetal movements, indicating fetal well-being. A 'reactive' NST, with two or more FHR accelerations within 20 minutes, suggests a healthy fetus. This test is a crucial non-invasive method to assess the baby's oxygenation and neurological status in the third trimester.

Question 12: A midwife is caring for a client who is a Jehovah's Witness and refuses blood products even in a life-threatening hemorrhage scenario. The midwife should:

Decline to provide intrapartum care for the client
Obtain a court order to transfuse if hemorrhage occurs
Agree verbally but arrange transfusion secretly if needed
Document the refusal thoroughly, ensure the client understands the risk, and plan aggressive non-blood management strategies (Correct answer)

Correct answer: Document the refusal thoroughly, ensure the client understands the risk, and plan aggressive non-blood management strategies

Competent adults have the right to refuse blood products; the midwife must document the informed refusal and prepare non-blood hemorrhage management strategies.

Question 13: Which medication is commonly used to control nausea and vomiting during pregnancy, especially in cases of hyperemesis gravidarum?

Ondansetron (Zofran) (Correct answer)
Diphenhydramine (Benadryl)
Labetalol
Metformin

Correct answer: Ondansetron (Zofran)

Ondansetron (Zofran) is an antiemetic medication commonly prescribed to manage severe nausea and vomiting during pregnancy, including hyperemesis gravidarum. It works by blocking serotonin receptors in the brain and gut, which are involved in triggering nausea and vomiting. While other medications exist, ondansetron is often chosen for its effectiveness and relatively favorable safety profile in pregnancy.

Question 14: During a water birth, which of the following is most important to ensure newborn safety at the moment of birth?

The placenta must be delivered underwater to prevent cord traction
The water temperature should be below 36°C to prevent hyperthermia
Pitocin should be withheld until the newborn is fully submerged for cord clamping
The newborn's face should be brought to the surface of water promptly after complete emergence of the body (Correct answer)

Correct answer: The newborn's face should be brought to the surface of water promptly after complete emergence of the body

While newborns can safely be born underwater, the face must be brought to air promptly once fully delivered to trigger the breathing response and prevent aspiration.

Question 15: What Edinburgh Postnatal Depression Scale (EPDS) score is the generally accepted threshold warranting further clinical evaluation?

Any score above zero requires immediate psychiatric referral
Score of 15 or higher
Score of 5 or higher
Score of 10 or higher (Correct answer)

Correct answer: Score of 10 or higher

An EPDS score of 10 or higher indicates possible postpartum depression and warrants further clinical assessment and follow-up by the midwife or referral.

Question 16: Which clinical finding best differentiates true labor from Braxton Hicks contractions?

Progressive cervical dilation with contractions that increase in frequency and intensity (Correct answer)
Contraction duration greater than 30 seconds
Onset of contractions before 37 weeks gestation
Maternal report of lower backache

Correct answer: Progressive cervical dilation with contractions that increase in frequency and intensity

True labor produces progressive cervical change (effacement and dilation) alongside regular, increasingly intense contractions, whereas Braxton Hicks contractions are irregular and non-progressive.

Question 17: Which contraceptive method is considered safe to initiate immediately postpartum in a breastfeeding woman?

Progestin-only pills (mini-pill) (Correct answer)
Copper IUD (must wait until 6-week visit for insertion)
Transdermal estrogen-containing contraceptive patch
Combined estrogen-progestin oral contraceptive pills

Correct answer: Progestin-only pills (mini-pill)

Progestin-only methods do not suppress lactation and are safe to start immediately postpartum, whereas estrogen-containing contraceptives can reduce milk supply and are contraindicated in breastfeeding women until at least 6 weeks.

Question 18: Which assessment finding most reliably confirms that the placenta has separated before applying cord traction?

Firm uterine fundus at the umbilicus
Maternal urge to push
Lengthening of the umbilical cord at the introitus (Correct answer)
Cessation of vaginal bleeding

Correct answer: Lengthening of the umbilical cord at the introitus

Cord lengthening (Strassman's/Küstner's sign) at the vaginal introitus is the most reliable sign of placental separation before controlled cord traction.

Question 19: During a water birth, the midwife observes the infant born completely submerged and limp. What is the first action after lifting the infant from the water?

Immediately begin chest compressions
Administer blow-by oxygen
Clamp and cut the cord before assessment
Stimulate by rubbing the back and assess breathing (Correct answer)

Correct answer: Stimulate by rubbing the back and assess breathing

Initial newborn resuscitation begins with drying, stimulation, and assessment of breathing and heart rate before escalating to more aggressive interventions.

Question 20: A client with a history of postpartum depression asks about antidepressant use while breastfeeding. Which SSRI has the LOWEST transfer into breast milk and is generally preferred?

Paroxetine (Paxil)
Fluoxetine (Prozac)
Citalopram (Celexa)
Sertraline (Zoloft) (Correct answer)

Correct answer: Sertraline (Zoloft)

Sertraline has the lowest relative infant dose (RID <2%) among SSRIs and is considered the preferred antidepressant during breastfeeding.

Question 21: Purpose of newborn metabolic screen?

Determine intelligence
Test allergies
Measure growth rate
Detect treatable genetic/metabolic conditions before symptoms appear (Correct answer)

Correct answer: Detect treatable genetic/metabolic conditions before symptoms appear

Early detection enables treatment before irreversible damage.

Question 22: A client experiencing postpartum hemorrhage has a firmly contracted uterus and ongoing vaginal bleeding. The most likely source of bleeding is:

Uterine inversion
Genital tract laceration (Correct answer)
Uterine atony
Retained placental fragments

Correct answer: Genital tract laceration

When the uterus is well-contracted yet bleeding continues, a laceration of the cervix, vagina, or perineum is the most probable cause and requires thorough inspection.

Question 23: Proper newborn resuscitation steps?

Submerge in water
Warm, dry, stimulate; position airway; PPV if needed (Correct answer)
Immediate medications
Wait 10 minutes

Correct answer: Warm, dry, stimulate; position airway; PPV if needed

A stepwise approach starts with simple interventions.

Question 24: What is the standard prenatal visit schedule for normal pregnancy?

Monthly until 28wk, biweekly until 36wk, weekly until delivery (Correct answer)
Weekly throughout
Monthly throughout
Three visits total

Correct answer: Monthly until 28wk, biweekly until 36wk, weekly until delivery

Visit frequency increases as pregnancy progresses.

Question 25: A breastfeeding client asks if she can take ibuprofen for afterpains. Which statement reflects the best evidence-based guidance?

Ibuprofen should be replaced with aspirin for breastfeeding mothers
Ibuprofen is compatible with breastfeeding as minimal amounts transfer into breast milk (Correct answer)
Ibuprofen use requires a 4-hour pump-and-discard period
Ibuprofen is contraindicated in breastfeeding mothers

Correct answer: Ibuprofen is compatible with breastfeeding as minimal amounts transfer into breast milk

Ibuprofen is considered safe during breastfeeding because it has low oral bioavailability and minimal transfer into breast milk.

Question 26: A midwife discovers that a client's partner has been absent from all prenatal visits and the client appears anxious when asked about him. What is the most appropriate initial action?

Report the situation to child protective services immediately
Discharge the client to a physician who can better manage complex social situations
Contact the partner directly to discuss his involvement in prenatal care
Document the observation and screen for intimate partner violence using a validated tool (Correct answer)

Correct answer: Document the observation and screen for intimate partner violence using a validated tool

Universal IPV screening using validated tools (e.g., HITS or WAST) is standard of care and allows the midwife to assess safety while respecting client autonomy.

Question 27: Which of the following situations requires mandatory reporting by a midwife in all U.S. jurisdictions?

A client who declines prenatal genetic screening
Reasonable suspicion of child abuse or neglect (Correct answer)
A client who smokes cigarettes during pregnancy
A client with a history of depression who is currently stable

Correct answer: Reasonable suspicion of child abuse or neglect

All U.S. states require mandatory reporting of reasonable suspicion of child abuse or neglect by healthcare providers, including midwives.

Question 28: When managing a third-degree perineal laceration, which structure differentiates a third-degree from a second-degree tear?

Vaginal mucosa
Internal anal sphincter
Perineal skin
External anal sphincter (Correct answer)

Correct answer: External anal sphincter

A third-degree laceration involves the external anal sphincter, distinguishing it from a second-degree tear which involves the perineal muscles but not the sphincter.

Question 29: A laboring client's membranes rupture spontaneously and you note green-stained fluid with thick particulate matter. Your immediate priority is:

Perform an immediate vaginal exam to check for cord prolapse
Place client in Trendelenburg position
Administer oxygen at 10 L/min via non-rebreather mask
Assess fetal heart rate and prepare for possible neonatal resuscitation (Correct answer)

Correct answer: Assess fetal heart rate and prepare for possible neonatal resuscitation

Thick meconium-stained amniotic fluid signals fetal stress; the priority is continuous FHR monitoring and alerting the neonatal team for potential airway suctioning and resuscitation.

Question 30: What is the mechanism of action of magnesium sulfate when used for eclampsia prophylaxis?

Enhances GABA activity to produce CNS sedation
Stabilizes neuronal membranes by competing with calcium at receptor sites (Correct answer)
Blocks calcium channels in smooth muscle, reducing blood pressure
Inhibits prostaglandin synthesis, reducing neuroinflammation

Correct answer: Stabilizes neuronal membranes by competing with calcium at receptor sites

Magnesium sulfate prevents seizures by competing with calcium at N-methyl-D-aspartate (NMDA) receptors, stabilizing neuronal membrane excitability.

Question 31: Which controlled substance schedule is assigned to buprenorphine/naloxone (Suboxone) used for opioid use disorder treatment in pregnancy?

Schedule III (Correct answer)
Schedule II
Schedule V
Schedule IV

Correct answer: Schedule III

Buprenorphine-containing products like Suboxone are classified as Schedule III controlled substances by the DEA.

Question 32: How to distinguish true from false labor?

True starts in back only
False is painful, true is not
They are identical
True: regular progressive contractions with cervical change; false: irregular, no change (Correct answer)

Correct answer: True: regular progressive contractions with cervical change; false: irregular, no change

Progressive cervical change is the key difference.

Question 33: When performing the Rubin II maneuver for shoulder dystocia, in which direction is pressure applied to the anterior shoulder?

Upward toward the pubic symphysis
Away from the fetal face (abduction)
Toward the fetal face (adduction) (Correct answer)
Downward toward the sacrum

Correct answer: Toward the fetal face (adduction)

Rubin II applies pressure to the posterior aspect of the anterior shoulder pushing it toward the fetal chest (adduction), reducing the shoulder-to-shoulder diameter.

Question 34: A midwife attends a birth at which shoulder dystocia occurs. After successful delivery, she should:

Transfer the client to the hospital only if a birth injury is detected
Avoid documenting maneuvers in detail to prevent liability exposure
Proceed normally since the dystocia was resolved without injury
Document all maneuvers attempted, timing, personnel present, and newborn condition, and conduct a debrief with the family (Correct answer)

Correct answer: Document all maneuvers attempted, timing, personnel present, and newborn condition, and conduct a debrief with the family

Thorough documentation of all maneuvers, timing, personnel, and outcomes is essential after shoulder dystocia; a family debrief is also good professional practice.

Question 35: Which intervention is most effective in preventing postpartum hemorrhage?

Immediate cord clamping within 30 seconds of delivery
Keeping the mother in a supine position for 2 hours after birth
Routine episiotomy to reduce perineal trauma
Active management of the third stage of labor including uterotonics and controlled cord traction (Correct answer)

Correct answer: Active management of the third stage of labor including uterotonics and controlled cord traction

Active management of the third stage of labor — encompassing uterotonic administration, controlled cord traction, and uterine massage — is the evidence-based standard for significantly reducing postpartum hemorrhage.

Question 36: CPM scope of practice limitations?

Can prescribe all medications
No limitations
Physiologic pregnancies only; must refer complications to physicians (Correct answer)
Can perform surgery

Correct answer: Physiologic pregnancies only; must refer complications to physicians

This credential covers normal pregnancies with clear boundaries.

Question 37: A client at 20 weeks is found to have a fundal height of 24 cm and a single fetus on ultrasound. Which condition should be ruled out first?

Placenta previa
Uterine fibroids
Fetal macrosomia
Polyhydramnios (Correct answer)

Correct answer: Polyhydramnios

A fundal height measuring 4 or more centimeters larger than expected gestational weeks raises concern for polyhydramnios, which should be evaluated with ultrasound amniotic fluid index measurement.

Question 38: What is the expected rate of uterine fundal descent during normal postpartum involution?

Rises above the umbilicus on day 2 before beginning to descend
Remains at the umbilicus for the first 5 days postpartum
Returns to pre-pregnancy size within 2 weeks with no measurable daily change
Descends approximately 1 cm (one fingerbreadth) per day (Correct answer)

Correct answer: Descends approximately 1 cm (one fingerbreadth) per day

The uterine fundus descends approximately 1 cm (one fingerbreadth) per day, returning to the pelvic cavity by approximately 10–14 days postpartum.

Question 39: When administering Vitamin K (phytonadione) to a newborn, what is the correct intramuscular dose?

2 mg
0.5 mg
1 mg (Correct answer)
0.1 mg

Correct answer: 1 mg

The standard prophylactic dose of Vitamin K1 for newborns is 1 mg IM, given within 6 hours of birth.

Question 40: A client in preterm labor at 32 weeks is given betamethasone. What is the primary therapeutic goal of this medication?

Accelerate fetal lung maturation by stimulating surfactant production (Correct answer)
Reduce maternal fever that is triggering labor
Prevent intraventricular hemorrhage by reducing fetal heart rate variability
Arrest uterine contractions to prolong pregnancy

Correct answer: Accelerate fetal lung maturation by stimulating surfactant production

Antenatal corticosteroids like betamethasone stimulate fetal type II pneumocyte maturation, increasing surfactant production and reducing the risk of neonatal respiratory distress syndrome.

Question 41: Normal newborn heart rate?

80-100 bpm
200-240 bpm
60-80 bpm
120-160 bpm (Correct answer)

Correct answer: 120-160 bpm

A newborns heart beats much faster than an adults.

Question 42: What are preeclampsia warning signs?

High blood pressure, proteinuria, headaches, vision changes, sudden swelling (Correct answer)
Low blood pressure
Weight loss
Mild nausea only

Correct answer: High blood pressure, proteinuria, headaches, vision changes, sudden swelling

This condition involves hypertension with multiple symptoms.

Question 43: Which of the following is a core tenet of the midwifery model of care as recognized by MANA and reflected in NARM competencies?

Mandatory physician co-management for all clients
Standardized intervention protocols regardless of individual client circumstances
Routine use of electronic fetal monitoring for all low-risk labors
Watchful waiting and non-intervention in normal processes unless warranted (Correct answer)

Correct answer: Watchful waiting and non-intervention in normal processes unless warranted

The midwifery model emphasizes supporting physiologic birth, avoiding unnecessary interventions, and individualizing care based on client needs.

Question 44: Which is the first action a midwife should take if a patient experiences a postpartum hemorrhage?

Assess and manage uterine tone and administer uterotonics (Correct answer)
Perform a manual placenta removal
Prepare for an emergency cesarean section
Administer intravenous antibiotics

Correct answer: Assess and manage uterine tone and administer uterotonics

Postpartum hemorrhage is most commonly caused by uterine atony, where the uterus fails to contract adequately after birth. Therefore, the first and most critical action for a midwife is to rapidly assess uterine tone by palpating the fundus and initiate interventions to promote uterine contraction, such as uterine massage and administering uterotonic medications like oxytocin. Prompt management of uterine atony is essential to control bleeding and prevent severe maternal morbidity.

Question 45: When assessing a newborn's Apgar score at 1 minute and 5 minutes after birth, which of the following is NOT a criterion used in the scoring?

Muscle tone
Respiratory effort
Heart rate
Birth weight (Correct answer)

Correct answer: Birth weight

The Apgar score assesses five criteria: Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration (breathing effort). Each criterion is scored from 0-2, with a total score indicating the newborn's overall condition. Birth weight is an important measurement for newborn health but is not one of the components of the Apgar scoring system.

Question 46: Which intervention is contraindicated when managing a prolapsed umbilical cord prior to delivery?

Elevating the presenting part manually
Pushing the cord back through the cervix (Correct answer)
Placing the client in knee-chest position
Keeping the cord warm and moist if exposed

Correct answer: Pushing the cord back through the cervix

Attempting to replace a prolapsed cord back through the cervix is contraindicated as it can cause cord vasospasm and further compromise fetal circulation.

Question 47: What does fundal height measure?

Baby weight precisely
Baby gender
Uterus growth from pubic bone to top, tracking fetal development (Correct answer)
Mother height

Correct answer: Uterus growth from pubic bone to top, tracking fetal development

This external measurement tracks pregnancy growth.

Question 48: A newborn at 5 minutes of life has a heart rate of 105 bpm, weak cry, some flexion, grimace response to stimulation, and pink body with blue extremities. What is the Apgar score?

5
6
7 (Correct answer)
8

Correct answer: 7

Scoring: HR >100 (2) + weak cry (1) + some flexion (1) + grimace (1) + pink body/blue extremities (1) = 7.

Question 49: What is a nuchal cord?

Cord infection
Umbilical cord around babys neck - managed by reducing over head or clamping/cutting (Correct answer)
Short cord
Cord knot

Correct answer: Umbilical cord around babys neck - managed by reducing over head or clamping/cutting

This common finding involves the cord around the neck.

Question 50: Which statement best distinguishes postpartum blues from postpartum depression?

Both conditions require psychiatric hospitalization and medication management
Postpartum depression always begins within 24 hours of delivery
Postpartum blues requires initiation of antidepressant therapy
Postpartum blues typically resolves spontaneously within 10–14 days without treatment (Correct answer)

Correct answer: Postpartum blues typically resolves spontaneously within 10–14 days without treatment

Postpartum blues affects up to 80% of new mothers and resolves on its own within 10–14 days; postpartum depression persists beyond this window and may require clinical intervention.

Question 51: What is shoulder dystocia?

Breech type
Mothers shoulder issue
Babys shoulder stuck behind pubic bone during delivery - emergency (Correct answer)
Normal delivery part

Correct answer: Babys shoulder stuck behind pubic bone during delivery - emergency

This emergency occurs when the baby gets stuck during delivery.

Question 52: Which finding indicates an infant has achieved an adequate breastfeeding latch?

The infant's mouth covers most of the areola with lips flanged outward (Correct answer)
Audible clicking sounds are heard with each suck
The infant's lips are pursed tightly around only the nipple
The infant suckles for fewer than 5 minutes per breast before falling asleep

Correct answer: The infant's mouth covers most of the areola with lips flanged outward

A proper latch is characterized by the infant's mouth covering most of the areola with lips flanged outward, ensuring effective milk transfer and preventing nipple trauma.

Question 53: Normal newborn respiratory rate?

8-12
12-20
30-60 breaths per minute (Correct answer)
80-100

Correct answer: 30-60 breaths per minute

Newborns breathe much faster than adults.

Question 54: During neonatal resuscitation, after 60 seconds of effective chest compressions and ventilation with no improvement in heart rate, epinephrine is indicated. What is the preferred route of administration?

Endotracheal tube
Umbilical vein catheter (Correct answer)
Intraosseous route
Intramuscular injection

Correct answer: Umbilical vein catheter

Umbilical vein catheterization is the preferred vascular access route for epinephrine administration during neonatal resuscitation per NRP guidelines.

Question 55: A client at 34 weeks has severe preeclampsia with persistent headache. Which antihypertensive is recommended as first-line acute treatment for severe-range blood pressure (≥160/110) in obstetric settings?

IV enalaprilat 1.25 mg
IV hydralazine 5–10 mg or IV labetalol 20 mg (Correct answer)
Oral labetalol 200 mg PO
Oral nifedipine 30 mg extended release

Correct answer: IV hydralazine 5–10 mg or IV labetalol 20 mg

IV hydralazine or IV labetalol are first-line agents for acute severe-range hypertension in pregnancy per ACOG, with oral nifedipine immediate-release as an alternative.

Question 56: A primigravida at 41+3 weeks has a Bishop score of 3. Which cervical ripening method is most appropriate prior to induction?

Artificial rupture of membranes
Membrane sweep only
Oxytocin infusion alone
Prostaglandin E2 gel or misoprostol (Correct answer)

Correct answer: Prostaglandin E2 gel or misoprostol

An unfavorable cervix (Bishop score ≤6) benefits from cervical ripening with prostaglandins before oxytocin induction to improve success rates.

Question 57: What is the primary purpose of a midwife maintaining a signed, written informed consent document for planned home birth?

To fulfill a hospital transfer prerequisite
To document that the client received, understood, and accepted the risks, benefits, and alternatives to planned home birth (Correct answer)
To limit the midwife's liability regardless of standard of care
To satisfy insurance billing requirements

Correct answer: To document that the client received, understood, and accepted the risks, benefits, and alternatives to planned home birth

Written informed consent documents the process of client education and voluntary decision-making, supporting both ethical practice and professional accountability.

Question 58: What is the Apgar score?

Pain scale
1 and 5 minute assessment of appearance, pulse, grimace, activity, respiration (Correct answer)
Pregnancy risk score
Genetic screen

Correct answer: 1 and 5 minute assessment of appearance, pulse, grimace, activity, respiration

Five newborn parameters are scored immediately after birth.

Question 59: What is normal fetal heart rate during labor?

180-220 bpm
200-240 bpm
110-160 beats per minute (Correct answer)
60-80 bpm

Correct answer: 110-160 beats per minute

Normal range is faster than an adult heart rate.

Question 60: A newborn at 2 minutes of age has gasping respirations, heart rate of 90 bpm, limp tone, no response to stimulation, and blue color throughout. What Apgar score does this represent?

3 (Correct answer)
4
2
1

Correct answer: 3

Scoring: HR 60-100 (1) + gasping (1) + limp (0) + no response (0) + blue (0) = 3; this indicates severe neonatal depression requiring immediate resuscitation.

Question 61: What supplements are essential during pregnancy?

No supplements needed
Only vitamin C
Folic acid, iron, calcium, prenatal vitamins (Correct answer)
Only calcium

Correct answer: Folic acid, iron, calcium, prenatal vitamins

Several nutrients prevent defects and support fetal development.

Question 62: What is the correct technique for bimanual compression of the uterus to manage postpartum hemorrhage from uterine atony?

One fist inside the uterus, other hand pushing the fundus downward externally
Both hands placed on the abdomen compressing the uterus laterally
One hand inside the vagina forming a fist, other hand compressing the uterus abdominally from the front and back (Correct answer)
One hand on the fundus, other hand applying suprapubic pressure

Correct answer: One hand inside the vagina forming a fist, other hand compressing the uterus abdominally from the front and back

Bimanual compression involves placing a fist in the anterior vaginal fornix while the abdominal hand compresses the posterior uterine wall, sandwiching the uterus to promote contraction.

Question 63: A neonate born to a mother on methadone maintenance therapy shows signs of neonatal opioid withdrawal syndrome (NOWS). Which clinical scoring tool is most commonly used to assess severity?

Ballard Score
Finnegan Neonatal Abstinence Scoring System (Correct answer)
LATCH breastfeeding assessment
Apgar Score

Correct answer: Finnegan Neonatal Abstinence Scoring System

The Finnegan Neonatal Abstinence Scoring System (FNASS) is the standard tool for assessing the severity of neonatal opioid withdrawal and guiding pharmacologic treatment.

Question 64: A midwife suspects a newborn has a critical congenital heart defect after birth. Which assessment finding most strongly supports this concern?

Heart rate of 148 beats per minute
Pre- and post-ductal oxygen saturation difference greater than 3% (Correct answer)
Oxygen saturation of 99% on the right hand
Mild acrocyanosis at 5 minutes of age

Correct answer: Pre- and post-ductal oxygen saturation difference greater than 3%

A pre- and post-ductal SpO2 difference greater than 3% is a key indicator of critical congenital heart disease (CCHD) and requires urgent evaluation.

Question 65: What is cervical insufficiency?

Cesarean complication
Normal late pregnancy
An infection type
Premature cervical dilation potentially causing preterm birth (Correct answer)

Correct answer: Premature cervical dilation potentially causing preterm birth

The cervix opens too early in pregnancy.

Question 66: Which medication used for nausea and vomiting of pregnancy (NVP) is classified as a combination antihistamine/Vitamin B6 product?

Ondansetron (Zofran)
Promethazine (Phenergan)
Metoclopramide (Reglan)
Doxylamine-pyridoxine (Diclegis/Bonjesta) (Correct answer)

Correct answer: Doxylamine-pyridoxine (Diclegis/Bonjesta)

Doxylamine succinate/pyridoxine HCl (Diclegis) is the only FDA-approved medication specifically indicated for NVP, combining an antihistamine with Vitamin B6.

Question 67: What is a biophysical profile?

Psychological profile
Blood test
Fitness level
Comprehensive fetal assessment: movement, tone, breathing, fluid, and NST (Correct answer)

Correct answer: Comprehensive fetal assessment: movement, tone, breathing, fluid, and NST

Multiple aspects of fetal health are evaluated simultaneously.

Question 68: What are the three stages of labor?

Cervical dilation, delivery of baby, delivery of placenta (Correct answer)
Contractions, delivery, recovery
Admission, delivery, discharge
Early, active, transition

Correct answer: Cervical dilation, delivery of baby, delivery of placenta

Labor has three distinct stages from start to completion.

Question 69: Which condition is characterized by severe hypertension and proteinuria during pregnancy and requires immediate medical intervention?

Gestational diabetes
Preterm labor
Hyperemesis gravidarum
Eclampsia (Correct answer)

Correct answer: Eclampsia

Eclampsia is a severe and life-threatening complication of pregnancy characterized by the onset of seizures in a woman with preeclampsia (hypertension and proteinuria). It represents the most severe form of the preeclamptic spectrum and requires immediate medical intervention to prevent serious maternal and fetal morbidity or mortality. Recognizing and treating eclampsia promptly is critical for both maternal and fetal well-being.

Question 70: What is the primary use of magnesium sulfate in obstetric care?

To relieve severe nausea and vomiting in pregnancy
To manage postpartum hemorrhage
To treat preeclampsia and prevent seizures (Correct answer)
To induce labor

Correct answer: To treat preeclampsia and prevent seizures

Magnesium sulfate is a critical medication in obstetric care primarily used to prevent and treat seizures (eclampsia) in women with severe preeclampsia or eclampsia. It acts as a central nervous system depressant and a vasodilator, helping to stabilize neuronal excitability and reduce blood pressure. While it has other uses, its role in seizure prophylaxis for preeclampsia is paramount.

Question 71: During a vaginal exam in labor you palpate the posterior fontanelle in the left occiput posterior (LOP) position. Which fetal movement would most likely result in spontaneous rotation to occiput anterior?

Asynclitism of the parietal bones
Long arc rotation of 135 degrees from LOP to OA (Correct answer)
Extension of the fetal head
Short arc rotation of 45 degrees to direct occiput posterior

Correct answer: Long arc rotation of 135 degrees from LOP to OA

LOP typically rotates via long arc (135°) to OA, which is the most favorable position for descent and delivery through the pelvic outlet.

Question 72: What is the golden hour after birth?

Paperwork completion time
Arbitrary timeframe
First hour of skin-to-skin promoting bonding, temperature regulation, breastfeeding (Correct answer)
Monitoring only hour

Correct answer: First hour of skin-to-skin promoting bonding, temperature regulation, breastfeeding

This critical first hour focuses on mother-baby contact.

Question 73: A client at 34 weeks gestation presents with sudden-onset severe headache, visual disturbances, and a BP of 162/110 mmHg. What is the priority action?

Encourage bed rest and increased fluid intake
Administer magnesium sulfate and transfer immediately (Correct answer)
Recheck blood pressure in 30 minutes
Perform non-stress test and observe for one hour

Correct answer: Administer magnesium sulfate and transfer immediately

BP ≥160/110 with neurological symptoms indicates severe-range preeclampsia requiring magnesium sulfate for seizure prophylaxis and immediate hospital transfer.

Question 74: A client at 34 weeks is in preterm labor with cervical dilation of 6 cm and intact membranes. The fetus is in breech presentation. Which statement regarding management is most accurate for an out-of-hospital midwife?

Prepare for vaginal breech delivery using the Burns-Marshall technique
Facilitate immediate transport to hospital, supporting the client during transfer (Correct answer)
Await spontaneous version and plan vaginal delivery if vertex
Attempt external cephalic version before complete dilation

Correct answer: Facilitate immediate transport to hospital, supporting the client during transfer

Preterm breech at 34 weeks at 6 cm in an out-of-hospital setting requires urgent transfer to a hospital capable of cesarean delivery, as the risks of out-of-hospital breech delivery are high.

Question 75: A midwife is asked by a journalism student to share anonymized case details about an unusual birth outcome. What should the midwife do?

Share details freely since they are anonymized
Decline unless the student provides IRB approval
Obtain written client authorization before sharing any case information (Correct answer)
Share only with a signed non-disclosure agreement from the student

Correct answer: Obtain written client authorization before sharing any case information

Even anonymized information can sometimes be re-identified; written client authorization is required before sharing any case details outside the professional care team.

Question 76: A client at 32 weeks gestation is at risk for preterm labor. Which tocolytic agent is contraindicated in clients with cardiac disease?

Magnesium sulfate
Terbutaline (beta-agonist) (Correct answer)
Nifedipine
Indomethacin

Correct answer: Terbutaline (beta-agonist)

Beta-agonists like terbutaline cause maternal tachycardia and cardiovascular stimulation, making them contraindicated in clients with significant cardiac disease.

Question 77: A client at 38 weeks gestation has a postpartum hemorrhage risk. Which medication is the FIRST-LINE uterotonic recommended by ACOG and used by CPMs within their scope?

Oxytocin 10 units IM (Correct answer)
Misoprostol 600 mcg sublingual
Carboprost 250 mcg IM
Methylergonovine 0.2 mg IM

Correct answer: Oxytocin 10 units IM

Oxytocin 10 units IM is the first-line uterotonic for postpartum hemorrhage prevention and treatment per ACOG guidelines.

Question 78: Which laboratory value is most consistent with HELLP syndrome in a 38-week client presenting with epigastric pain and malaise?

Proteinuria 2+ with normal liver enzymes
Hemoglobin of 10.2 g/dL with normal platelets
Platelet count of 85,000/µL with elevated AST and LDH (Correct answer)
Elevated creatinine with normal platelets and liver enzymes

Correct answer: Platelet count of 85,000/µL with elevated AST and LDH

HELLP syndrome is characterized by Hemolytic anemia, Elevated Liver enzymes, and Low Platelets; thrombocytopenia with elevated AST and LDH are hallmark findings.

Question 79: Normal weight loss in breastfed newborns?

No loss should occur
Up to 7-10% in first days, regained by 10-14 days (Correct answer)
Immediate weight gain
50% loss normal

Correct answer: Up to 7-10% in first days, regained by 10-14 days

Initial weight loss is normal and temporary.

Question 80: A laboring client at 9 cm suddenly becomes unresponsive and seizing with no prior history of hypertension. After ensuring airway safety, what is the immediate pharmacologic treatment?

Phenobarbital 20mg/kg IV
Magnesium sulfate 4-6g IV over 15-20 minutes (Correct answer)
Diazepam 10mg IM
Lorazepam 4mg IV push

Correct answer: Magnesium sulfate 4-6g IV over 15-20 minutes

Any new-onset seizure in a pregnant or postpartum client must be treated as eclampsia; magnesium sulfate is the first-line treatment and prevents recurrent seizures.

Question 81: What is the recommended initial management of uterine inversion before attempting replacement?

Administer a tocolytic agent to relax the uterus, then attempt replacement (Correct answer)
Attempt manual replacement immediately without tocolysis
Pack the vagina with gauze and transport
Administer oxytocin IV to contract the uterus first

Correct answer: Administer a tocolytic agent to relax the uterus, then attempt replacement

Uterine relaxation with a tocolytic (e.g., terbutaline or nitroglycerin) is recommended before manual replacement to ease the uterus back through the cervical ring.

Question 82: A client develops sudden onset shortness of breath, hypotension, and altered mental status immediately following rupture of membranes at 38 weeks. What rare but catastrophic complication should be suspected?

Amniotic fluid embolism (Correct answer)
Pulmonary embolism
Tension pneumothorax
Severe preeclampsia

Correct answer: Amniotic fluid embolism

Amniotic fluid embolism (AFE) classically presents with sudden cardiovascular collapse, respiratory distress, and DIC following amniotomy or ROM, and has high maternal mortality.

Question 83: What is the primary purpose of cultural competency in midwifery practice?

To enhance communication and provide respectful, individualized care that acknowledges and respects diverse cultural backgrounds (Correct answer)
To limit the range of care options based on cultural preferences
To conform to a specific cultural norm for all patients
To avoid addressing any cultural differences in care

Correct answer: To enhance communication and provide respectful, individualized care that acknowledges and respects diverse cultural backgrounds

Cultural competency in midwifery is vital for delivering high-quality, patient-centered care. It involves understanding and respecting the diverse beliefs, values, and practices of clients from various cultural backgrounds. By being culturally competent, midwives can tailor communication and care plans to be sensitive and appropriate, fostering trust and ensuring that care is individualized and respectful of each client's unique cultural context.

Question 84: What is a primary goal of maintaining effective communication with clients in midwifery?

To ensure that the midwife is not liable for any adverse outcomes
To build trust and provide clear information to support informed decision-making (Correct answer)
To control the client's choices in their care
To minimize the amount of time spent on each client’s case

Correct answer: To build trust and provide clear information to support informed decision-making

Effective communication is paramount in midwifery because it fosters a strong, trusting relationship between the midwife and the client. This trust is essential for open dialogue, allowing the midwife to provide clear, comprehensive information about pregnancy, birth, and postpartum care. Ultimately, this empowers clients to make well-informed decisions that align with their values and preferences throughout their care journey.

Question 85: A newborn's blood glucose at 1 hour of life is 38 mg/dL and the infant is asymptomatic. The best initial management is:

Early breastfeeding or formula feeding followed by glucose recheck in 30–60 minutes (Correct answer)
Administer glucagon IM and recheck in 2 hours
Transfer to NICU for continuous glucose monitoring
Immediate IV dextrose infusion

Correct answer: Early breastfeeding or formula feeding followed by glucose recheck in 30–60 minutes

Asymptomatic neonatal hypoglycemia (glucose 36–45 mg/dL) in a term newborn is first managed with early feeding and recheck; IV glucose is reserved for symptomatic or severely hypoglycemic neonates.

Question 86: When should midwife-to-physician transfer occur?

Preeclampsia, GDM needing medication, preterm labor, breech after 37wk (Correct answer)
Only first pregnancies
Only if mother requests
Never

Correct answer: Preeclampsia, GDM needing medication, preterm labor, breech after 37wk

Certain complications require medical intervention.

Question 87: What is gestational diabetes screening?

Glucose tolerance test at 24-28 weeks for diabetes developing during pregnancy (Correct answer)
A permanent diabetes test
A baby-only condition test
A genetic test

Correct answer: Glucose tolerance test at 24-28 weeks for diabetes developing during pregnancy

This condition is screened in the second trimester.

Question 88: A midwife is providing postpartum care and notices the client's newborn has a yellow tint at 20 hours of age. The most appropriate action is:

Advise increased breastfeeding only and recheck at the 2-week visit
Reassure the mother that jaundice at this age is normal physiologic jaundice
Arrange urgent evaluation including a total serum or transcutaneous bilirubin, as jaundice before 24 hours is pathologic until proven otherwise (Correct answer)
Begin phototherapy at home with a bilirubin blanket immediately

Correct answer: Arrange urgent evaluation including a total serum or transcutaneous bilirubin, as jaundice before 24 hours is pathologic until proven otherwise

Jaundice appearing before 24 hours of age is considered pathologic and requires urgent evaluation to rule out hemolytic disease or other serious causes.

Question 89: A client at 36 weeks is prescribed nifedipine for tocolysis. Which side effect should the midwife anticipate and monitor?

Pulmonary edema and fluid overload
Maternal hypotension and reflex tachycardia (Correct answer)
Hyperkalemia and bradycardia
Uterine hyperstimulation and fetal distress

Correct answer: Maternal hypotension and reflex tachycardia

Nifedipine, a calcium channel blocker, causes peripheral vasodilation leading to maternal hypotension and compensatory reflex tachycardia.

Question 90: A client at 38 weeks develops a temperature of 38.5°C (101.3°F) in active labor with rupture of membranes for 18 hours. The most likely diagnosis is:

Intra-amniotic infection (chorioamnionitis) (Correct answer)
Urinary tract infection
Normal physiological response to labor
Epidural-related fever

Correct answer: Intra-amniotic infection (chorioamnionitis)

Fever after prolonged rupture of membranes strongly suggests intra-amniotic infection (chorioamnionitis), which requires antibiotics and expedited delivery.

Question 91: What is postpartum hemorrhage?

Labor bleeding
First trimester bleeding
Any post-delivery bleeding
Blood loss 500ml+ after vaginal delivery within 24 hours (Correct answer)

Correct answer: Blood loss 500ml+ after vaginal delivery within 24 hours

A specific volume threshold defines this dangerous condition.

Question 92: What are ectopic pregnancy signs?

Increased appetite
Normal symptoms
Morning sickness
Sharp abdominal pain, vaginal bleeding, dizziness - pregnancy outside uterus (Correct answer)

Correct answer: Sharp abdominal pain, vaginal bleeding, dizziness - pregnancy outside uterus

This emergency involves implantation in the wrong location.

Question 93: What is Group B Strep screening?

Test at 35-37 weeks for bacteria that could infect baby during birth (Correct answer)
Blood type test
Strep throat test
STI test

Correct answer: Test at 35-37 weeks for bacteria that could infect baby during birth

Late-pregnancy test identifies bacteria affecting the baby during delivery.

Question 94: A client has a shoulder dystocia with the anterior shoulder impacted behind the pubic symphysis. After McRoberts maneuver and suprapubic pressure fail, what is the next maneuver?

Rubin II or Woods screw maneuver (Correct answer)
Zavanelli maneuver
Fundal pressure
Kristeller expression

Correct answer: Rubin II or Woods screw maneuver

Rubin II (internal rotation of the anterior shoulder toward the fetal chest) or the Woods screw maneuver (rotating the posterior shoulder) are the recommended next steps after McRoberts and suprapubic pressure fail.

Question 95: Why is vitamin K given to newborns?

Prevents jaundice
Improves vision
Boosts immunity
Prevents hemorrhagic disease by supporting clotting (Correct answer)

Correct answer: Prevents hemorrhagic disease by supporting clotting

Newborns cannot produce adequate clotting factors.

Question 96: Which of the following best describes cultural humility in midwifery practice?

Maintaining a lifelong commitment to self-reflection and addressing power imbalances in the client-provider relationship (Correct answer)
Avoiding discussion of cultural differences to prevent offense
Learning a fixed set of cultural practices for each patient population served
Delegating cultural considerations to a cultural liaison

Correct answer: Maintaining a lifelong commitment to self-reflection and addressing power imbalances in the client-provider relationship

Cultural humility is a dynamic, ongoing practice of self-reflection and power-awareness that goes beyond learning static cultural facts.

Question 97: According to updated ACOG guidelines, what is the recommended postpartum care timeline for low-risk vaginal delivery clients?

Weekly midwife visits for all 6 weeks of the postpartum period
Postpartum care visits only when the client reports a specific complication
Initial contact within 3 weeks and a comprehensive visit completed by 12 weeks postpartum (Correct answer)
A single comprehensive visit at 6 weeks postpartum is sufficient

Correct answer: Initial contact within 3 weeks and a comprehensive visit completed by 12 weeks postpartum

ACOG (2018) updated guidance recommends initial postpartum contact within 3 weeks and a comprehensive postpartum visit completed no later than 12 weeks, recognizing that the traditional single 6-week visit is inadequate for detecting complications.

Question 98: Which description best characterizes normal lochia rubra?

Bright red discharge with large clots and an offensive odor throughout the first week
Dark red discharge containing decidual tissue that may include small clots, lasting 1–4 days (Correct answer)
Yellow-white creamy discharge present from birth through 6 weeks
Pink-brown watery discharge beginning immediately after delivery and lasting 3 weeks

Correct answer: Dark red discharge containing decidual tissue that may include small clots, lasting 1–4 days

Lochia rubra is dark red, may contain small clots and decidual tissue, and is normal for the first 1–4 days postpartum; large clots or foul odor would be abnormal findings.

Question 99: Purpose of peer review in midwifery?

Evaluate practice, promote quality, maintain standards (Correct answer)
Compete for clients
Criticize colleagues
Insurance requirement only

Correct answer: Evaluate practice, promote quality, maintain standards

Professional evaluation improves practice quality.

Question 100: What newborn screening tests are done?

Only blood type
Only weight/length
No screening
Blood spot for metabolic conditions, hearing screen, pulse oximetry (Correct answer)

Correct answer: Blood spot for metabolic conditions, hearing screen, pulse oximetry

Multiple different tests screen for various conditions.

Question 101: What is the maximum recommended dose of oxytocin for active management of the third stage of labor in a low-resource or home birth setting?

40 units IV drip
5 units IM
10 units IM (Correct answer)
20 units IM

Correct answer: 10 units IM

Ten units of oxytocin IM is the WHO-recommended standard dose for active management of the third stage of labor to prevent postpartum hemorrhage.

Question 102: What is a non-stress test?

Mothers stress test
Monitoring fetal heart rate response to movement to assess well-being (Correct answer)
Diabetes test
Position test

Correct answer: Monitoring fetal heart rate response to movement to assess well-being

This test watches heart rate patterns during fetal movement.

Question 103: Midwife role in emergency hospital transfer?

Initiate transfer, communicate clinical info, accompany client, continue support (Correct answer)
Leave when ambulance arrives
Only call 911
End care immediately

Correct answer: Initiate transfer, communicate clinical info, accompany client, continue support

Responsibilities continue throughout the transfer.

Question 104: According to NARM standards of practice, when should the first postpartum home visit occur after an uncomplicated home birth?

At 2 weeks postpartum only
Within 24–48 hours of delivery (Correct answer)
At the 6-week comprehensive visit
Only if the mother contacts the midwife with specific concerns

Correct answer: Within 24–48 hours of delivery

NARM standards require the attending midwife to conduct a home visit within 24–48 hours of delivery to assess maternal and newborn wellbeing and detect early complications.

Question 105: Emergency supplies required at birth?

Only towels
Resuscitation equipment, hemorrhage meds, suturing, oxygen, transport plan (Correct answer)
First aid kit only
No supplies for normal pregnancy

Correct answer: Resuscitation equipment, hemorrhage meds, suturing, oxygen, transport plan

Preparation for emergencies requires specific supplies.

Question 106: Which finding in a postpartum perineal wound is most indicative of infection requiring treatment?

Purulent discharge, worsening pain, and separation of wound edges (Correct answer)
Perineal edema requiring continued ice pack application
Slight swelling and tenderness at the suture line on day 2
Mild bruising and ecchymosis around the repair site on day 2

Correct answer: Purulent discharge, worsening pain, and separation of wound edges

Purulent discharge, escalating pain (rather than improving), and wound dehiscence are hallmark signs of perineal wound infection requiring antibiotic treatment and possible wound management.

Question 107: During auscultation at 28 weeks, the fetal heart rate baseline is 175 bpm over two consecutive 10-minute segments. This finding is best classified as:

Fetal bradycardia
Normal variation for gestational age
Sinusoidal pattern
Fetal tachycardia (Correct answer)

Correct answer: Fetal tachycardia

A baseline FHR above 160 bpm for ≥10 minutes is defined as fetal tachycardia and warrants investigation for causes such as infection, maternal fever, or hypoxia.

Question 108: Which of the following is a common sign of postpartum hemorrhage?

Persistent, severe headache
Temperature of 101°F (38.3°C)
A decrease in hematocrit levels (Correct answer)
Elevated blood pressure

Correct answer: A decrease in hematocrit levels

Postpartum hemorrhage (PPH) is excessive bleeding after childbirth, leading to significant blood loss. A decrease in hematocrit levels, which measures the proportion of red blood cells in the blood, is a direct indicator of blood loss and a key diagnostic sign of PPH. Other options like temperature or headache are not primary indicators of hemorrhage.

Question 109: Signs of neonatal respiratory distress?

Loud crying only
Normal sleep
Quiet breathing
Grunting, nasal flaring, retractions, tachypnea, cyanosis (Correct answer)

Correct answer: Grunting, nasal flaring, retractions, tachypnea, cyanosis

Multiple visible signs show breathing difficulty.

Question 110: Which of the following is the correct technique for performing Leopold's maneuver to determine fetal lie?

Press downward just above the pubic symphysis to assess engagement
Palpate the fundal area with both hands to identify the presenting pole (Correct answer)
Apply lateral pressure bilaterally to locate the fetal back
Use one hand to ballott the presenting part

Correct answer: Palpate the fundal area with both hands to identify the presenting pole

The first Leopold maneuver involves palpating the uterine fundus with both hands to determine which fetal pole occupies the fundus, establishing fetal lie.

Question 111: What is the recommended management for a patient presenting with a prolonged rupture of membranes (PROM) and signs of infection?

Initiate immediate labor induction with oxytocin
Administer a tocolytic agent to delay labor
Perform a cesarean section
Begin broad-spectrum intravenous antibiotics and monitor closely (Correct answer)

Correct answer: Begin broad-spectrum intravenous antibiotics and monitor closely

When a patient with prolonged rupture of membranes (PROM) shows signs of infection (e.g., fever, uterine tenderness, foul-smelling amniotic fluid), the primary concern is chorioamnionitis, a serious intra-amniotic infection. The immediate and appropriate management is to initiate broad-spectrum intravenous antibiotics to treat the infection and prevent its spread, while closely monitoring both mother and fetus. Delivery is often indicated once antibiotics are started, but the initial step is addressing the infection.

Question 112: What warrants emergency transport from home birth?

Only mother request
Never needed
Prolonged labor, fetal distress, hemorrhage, cord prolapse, unresolved shoulder dystocia (Correct answer)
Only first-time mothers

Correct answer: Prolonged labor, fetal distress, hemorrhage, cord prolapse, unresolved shoulder dystocia

Certain emergencies require hospital-level resources.

Question 113: During a home birth, a client develops a severe postpartum hemorrhage and IV access cannot be established. Which route can be used to administer oxytocin as an alternative?

Intranasal
Intramuscular (Correct answer)
Inhalation
Intrathecal

Correct answer: Intramuscular

Oxytocin can be administered intramuscularly (10 units IM) when IV access is unavailable, and is standard practice in out-of-hospital birth settings.

Question 114: Which station indicates that the leading bony part of the presenting part is at the level of the ischial spines?

+2 station
0 station (Correct answer)
-1 station
+1 station

Correct answer: 0 station

Station 0 means the presenting part is at the level of the ischial spines; negative stations are above and positive stations are below the spines.

Question 115: What is the recommended hepatitis B vaccine schedule for a newborn born to a hepatitis B surface antigen (HBsAg) POSITIVE mother?

Hepatitis B vaccine AND HBIG, both given within 12 hours of birth at different sites (Correct answer)
Hepatitis B vaccine only, within 12 hours of birth
Hepatitis B immune globulin (HBIG) only, within 12 hours, vaccine at 2 months
No immediate intervention; test infant at 6 months before deciding

Correct answer: Hepatitis B vaccine AND HBIG, both given within 12 hours of birth at different sites

Neonates born to HBsAg-positive mothers must receive both the hepatitis B vaccine AND HBIG (0.5 mL) at separate injection sites within 12 hours of birth to prevent perinatal transmission.

Question 116: Cultural competency in midwifery?

Only translation matters
Respect diverse practices and beliefs while maintaining safety (Correct answer)
Irrelevant to care
Impose standard practices

Correct answer: Respect diverse practices and beliefs while maintaining safety

Respecting diversity while maintaining safety is essential.

Question 117: When performing a bimanual examination to estimate uterine size at 8 weeks gestation, the uterus is most likely to feel approximately the size of a:

Large orange (Correct answer)
Grapefruit
Tennis ball
Walnut

Correct answer: Large orange

At 8 weeks, the uterus is approximately the size of a large orange (about 8 cm), double its non-pregnant size.

Question 118: What is active management of third stage?

Passive waiting
Starting breastfeeding
Immediate cord cutting
Uterotonic medication, controlled cord traction, uterine massage (Correct answer)

Correct answer: Uterotonic medication, controlled cord traction, uterine massage

Three interventions reduce postpartum hemorrhage risk.

Question 119: When should first breastfeeding occur?

After first bath
Within first hour during skin-to-skin (Correct answer)
24 hours later
After baby sleeps

Correct answer: Within first hour during skin-to-skin

Early initiation promotes successful lactation.

Question 120: During auscultation of fetal heart tones in active labor, the midwife hears a rate of 180 bpm persisting for 15 minutes. What is the most common cause of fetal tachycardia in labor?

Fetal cardiac arrhythmia
Maternal fever and chorioamnionitis (Correct answer)
Fetal anemia
Umbilical cord compression

Correct answer: Maternal fever and chorioamnionitis

Maternal fever from chorioamnionitis is the most common cause of fetal tachycardia in labor, as the elevated maternal temperature directly increases fetal heart rate.

Question 121: How does the NARM certification process differ from state licensure for CPMs?

NARM certification guarantees the legal right to practice in every U.S. state
They are identical processes administered by the same authority
State licensure supersedes and replaces the need for NARM certification
NARM certification is a national credential demonstrating competency, while state licensure grants the legal authority to practice within that state (Correct answer)

Correct answer: NARM certification is a national credential demonstrating competency, while state licensure grants the legal authority to practice within that state

NARM certification is a national credentialing process; state licensure is a separate legal authorization to practice that varies by state and may or may not require NARM certification.

Question 122: Which sign differentiates true placental abruption from placenta previa on clinical presentation?

Presence of painful uterine contractions or rigidity (Correct answer)
Maternal blood pressure
Fetal presentation
Vaginal bleeding color

Correct answer: Presence of painful uterine contractions or rigidity

Placental abruption typically causes painful, rigid uterus (dark bleeding may be concealed), whereas placenta previa presents with painless bright red bleeding.

Question 123: Iron supplementation is recommended during pregnancy. Which statement about iron absorption is correct?

Iron is best absorbed with milk to reduce GI irritation
Vitamin C (ascorbic acid) co-administration enhances iron absorption (Correct answer)
Ferric (Fe3+) iron salts are more bioavailable than ferrous (Fe2+) salts
Calcium supplements taken simultaneously increase iron bioavailability

Correct answer: Vitamin C (ascorbic acid) co-administration enhances iron absorption

Ascorbic acid (Vitamin C) reduces ferric to ferrous iron in the gut and forms a soluble chelate, significantly enhancing non-heme iron absorption.

Question 124: Which antibiotic is the standard prophylaxis given to GBS-positive clients in labor when they have no penicillin allergy?

Penicillin G 5 million units IV then 2.5 million units q4h (Correct answer)
Clindamycin 900 mg IV
Cefazolin 2 g IV then 1 g q8h
Ampicillin 2 g IV then 1 g q4h

Correct answer: Penicillin G 5 million units IV then 2.5 million units q4h

Penicillin G is the preferred agent for GBS intrapartum prophylaxis per CDC guidelines due to its narrow spectrum.

Question 125: What is intermittent auscultation?

Periodic fetal heart rate monitoring during labor using doppler (Correct answer)
Contraction measurement
Fluid level check
Mothers heartbeat check

Correct answer: Periodic fetal heart rate monitoring during labor using doppler

Periodic listening assesses fetal well-being during labor.

Question 126: What is meconium-stained fluid?

Bloody fluid
Fetal stool in amniotic fluid indicating possible distress and aspiration risk (Correct answer)
Normal fluid
Fluid with vernix

Correct answer: Fetal stool in amniotic fluid indicating possible distress and aspiration risk

Fetal stool in fluid can signal distress and create breathing risks.

Question 127: Which of the following best describes 'informed refusal' in midwifery care?

A client declines a recommended intervention after receiving complete information about risks and benefits (Correct answer)
A client refuses to sign consent forms and therefore cannot receive care
A client refuses care and the midwife terminates the professional relationship
A midwife refuses to perform a procedure outside her scope of practice

Correct answer: A client declines a recommended intervention after receiving complete information about risks and benefits

Informed refusal occurs when a fully informed client chooses to decline a recommended intervention, and the midwife must document this and continue to support the client.

Question 128: What is Rh factor importance in pregnancy?

Rh-negative mothers may develop antibodies against Rh-positive babies, requiring RhoGAM (Correct answer)
Blood sugar measure
A prenatal test type
A vitamin supplement

Correct answer: Rh-negative mothers may develop antibodies against Rh-positive babies, requiring RhoGAM

Blood protein mismatch can cause serious complications.

Question 129: What is the NARM certification process?

Written test only
Education program, clinical experience, written exam, skills assessment (Correct answer)
Weekend workshop
Self-certification

Correct answer: Education program, clinical experience, written exam, skills assessment

Multiple components are required for certification.

Question 130: A client at 41 weeks requires cervical ripening. Misoprostol (Cytotec) 25 mcg is placed vaginally. How frequently can doses be repeated if needed?

Every 3–4 hours (Correct answer)
Every 12 hours
Every 1 hour
Every 6 hours

Correct answer: Every 3–4 hours

Vaginal misoprostol 25 mcg may be repeated every 3–4 hours per ACOG protocol, with reassessment of fetal status before each dose.

Question 131: A client in active labor at a planned home birth develops a prolonged variable deceleration lasting 4 minutes that does not resolve with position changes and oxygen. The midwife should:

Perform an artificial rupture of membranes to assess for cord prolapse
Administer terbutaline and reassess in 15 minutes
Initiate emergency transfer to the hospital while continuing supportive measures (Correct answer)
Continue monitoring for another 10 minutes before making a decision

Correct answer: Initiate emergency transfer to the hospital while continuing supportive measures

A prolonged deceleration unresponsive to initial interventions is an obstetric emergency requiring immediate transfer to a facility capable of operative delivery.

Question 132: Which screening tool is most widely validated and recommended for postpartum depression screening in midwifery practice?

Hamilton Rating Scale for Depression (HAM-D)
Patient Health Questionnaire-2 (PHQ-2) alone
Beck Depression Inventory (BDI)
Edinburgh Postnatal Depression Scale (EPDS) (Correct answer)

Correct answer: Edinburgh Postnatal Depression Scale (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used and validated screening tool specifically designed and normed for the postpartum population.

Question 133: Which statement about oxytocin's pharmacokinetics during labor augmentation is accurate?

Dose increments should occur every 15–30 minutes to allow for steady state
Oxytocin has a half-life of approximately 3–5 minutes (Correct answer)
Oxytocin crosses the placenta and directly stimulates fetal myometrium
Steady-state plasma levels are achieved within 5 minutes of starting infusion

Correct answer: Oxytocin has a half-life of approximately 3–5 minutes

Oxytocin has a half-life of 3–5 minutes, and steady-state levels are achieved in approximately 20–40 minutes after initiating or changing infusion rates.

Question 134: A client at 37 weeks with gestational diabetes controlled by diet reports decreased fetal movement. Her fasting glucose this morning was 115 mg/dL. The priority action is:

Reassure the client that decreased movement is common near term
Perform a non-stress test and assess amniotic fluid index (Correct answer)
Schedule a routine biophysical profile for next week
Initiate insulin therapy and recheck movement tomorrow

Correct answer: Perform a non-stress test and assess amniotic fluid index

Decreased fetal movement with suboptimally controlled gestational diabetes requires immediate fetal evaluation via NST and AFI, as diabetic pregnancies carry increased risk of stillbirth near term.

Question 135: The NARM Skills Assessment requires demonstration of competency in which of the following?

Surgical first-assist techniques
Newborn resuscitation, including bag-mask ventilation (Correct answer)
Interpretation of fetal MRI imaging
Placement of epidural catheters

Correct answer: Newborn resuscitation, including bag-mask ventilation

Newborn resuscitation, including effective bag-mask ventilation, is a core clinical skill assessed in the NARM Skills Assessment for CPM candidates.

Question 136: What is the recommended dose and route for misoprostol when used to treat postpartum hemorrhage after oxytocin failure?

1000 mcg IV infusion
200 mcg sublingual
400 mcg intravaginally
600–800 mcg rectally or sublingually (Correct answer)

Correct answer: 600–800 mcg rectally or sublingually

For postpartum hemorrhage treatment, misoprostol 600–800 mcg is given rectally or sublingually when IV access is unavailable or oxytocin has failed.

Question 137: After repair of a second-degree perineal laceration, which perineal care instruction is most appropriate?

Apply ice packs continuously for 48 hours and avoid sitz baths for the first week
Use warm sitz baths, keep the perineum clean, and pat dry after voiding (Correct answer)
Change sterile dressings twice daily and apply antibiotic ointment to the suture line
Keep the area completely dry and avoid all water contact for 2 weeks

Correct answer: Use warm sitz baths, keep the perineum clean, and pat dry after voiding

Warm sitz baths, front-to-back wiping, and gentle drying after voiding promote healing and comfort while reducing infection risk following perineal laceration repair.

Question 138: Which finding during a newborn's initial assessment is a normal variant that requires no intervention?

Absent femoral pulses bilaterally
Epstein's pearls on the hard palate (Correct answer)
Respiratory rate of 68 breaths per minute at 2 hours of life
Unilateral absent red reflex

Correct answer: Epstein's pearls on the hard palate

Epstein's pearls are small, benign epithelial inclusion cysts on the hard palate that disappear spontaneously within weeks and require no treatment.

Question 139: A CPM practicing in a state where CPMs are not licensed receives a complaint from a client. Which entity has jurisdiction to investigate the complaint?

NARM, through its ethics and discipline process (Correct answer)
The local health department
No entity has jurisdiction in unlicensed states
The state medical board, since CPMs operate under physician oversight

Correct answer: NARM, through its ethics and discipline process

NARM has jurisdiction over CPM credential holders regardless of state licensure status through its own ethics and disciplinary process.

Question 140: After delivery of a macrosomic infant, the midwife notes the placenta delivers but then the uterine fundus follows it through the vaginal introitus. This describes which obstetric emergency?

Complete uterine atony
Uterine rupture
Uterine prolapse
Uterine inversion (Correct answer)

Correct answer: Uterine inversion

Uterine inversion occurs when the fundus turns inside out and descends into or through the vaginal canal, often associated with excessive cord traction or fundal pressure with an uncontracted uterus.

Question 141: A midwife is considering accepting a home birth client who is a grand multipara (gravida 7, para 6). Her most important next step is:

Conducting a thorough risk assessment addressing risks associated with grand multiparity including uterine atony and abnormal placentation (Correct answer)
Declining care automatically based on parity alone
Accepting care without special consideration since the client is experienced
Referring to a physician without offering consultation or risk assessment

Correct answer: Conducting a thorough risk assessment addressing risks associated with grand multiparity including uterine atony and abnormal placentation

Grand multiparity is a risk factor for complications such as postpartum hemorrhage from uterine atony and placenta previa; a thorough individualized risk assessment guides the care decision.

Question 142: What documentation is required per visit?

Vitals, fetal heart tones, fundal height, UA results, concerns, plan (Correct answer)
No documentation
Just weight
Only the date

Correct answer: Vitals, fetal heart tones, fundal height, UA results, concerns, plan

Comprehensive records are essential at every visit.

Question 143: What is neonatal hypoglycemia?

High blood sugar
Normal finding
Skin condition
Low blood sugar causing jitteriness, poor feeding, lethargy, possibly seizures (Correct answer)

Correct answer: Low blood sugar causing jitteriness, poor feeding, lethargy, possibly seizures

Low blood sugar requires prompt treatment.

Question 144: What is the expected timeframe for a postpartum woman to achieve her first spontaneous void after an uncomplicated vaginal delivery?

Within 24–48 hours of delivery
Within 3–5 days as perineal swelling resolves
Within 6–8 hours of delivery (Correct answer)
Within 1 hour of delivery

Correct answer: Within 6–8 hours of delivery

The first postpartum void should occur within 6–8 hours of delivery; inability to void within this timeframe warrants catheterization to prevent bladder distension.

Question 145: Which combination of findings is most consistent with postpartum endometritis?

Uterine tenderness on palpation, fever above 38°C, and foul-smelling lochia (Correct answer)
Lochia rubra on postpartum day 2 with mild uterine cramping
Mild lower abdominal cramping during breastfeeding sessions
Slight bilateral breast tenderness on postpartum day 3

Correct answer: Uterine tenderness on palpation, fever above 38°C, and foul-smelling lochia

Postpartum endometritis classically presents with uterine tenderness, fever (>38°C), and malodorous lochia and requires prompt antibiotic treatment.

Question 146: Which maternal vital sign change is the earliest indicator of significant postpartum hemorrhage before blood pressure drops?

Decreased temperature
Increased heart rate (tachycardia) (Correct answer)
Decreased respiratory rate
Increased oxygen saturation

Correct answer: Increased heart rate (tachycardia)

Tachycardia is typically the earliest compensatory response to hemorrhage and blood pressure may remain normal until 20-25% of blood volume is lost.

Question 147: A newborn is born limp and apneic at 1 minute of life. After 30 seconds of positive pressure ventilation, heart rate is 55 bpm. What is the next step?

Begin chest compressions at a 15:2 ratio
Administer epinephrine via umbilical vein
Begin chest compressions at a 3:1 ratio with PPV (Correct answer)
Continue PPV alone for another 30 seconds

Correct answer: Begin chest compressions at a 3:1 ratio with PPV

A heart rate below 60 bpm despite adequate PPV requires initiation of chest compressions at a 3:1 compression-to-ventilation ratio per NRP guidelines.

Question 148: A client at 36 weeks presents with painless bright red vaginal bleeding without contractions. Fetal heart tones are 145 bpm. What should the midwife do FIRST?

Apply fundal pressure to determine placental location
Perform a sterile vaginal exam to assess cervical dilation
Assess vital signs and call for emergency transport (Correct answer)
Administer 500mL IV fluid bolus

Correct answer: Assess vital signs and call for emergency transport

Painless bright red bleeding at 36 weeks is a classic presentation of placenta previa; digital vaginal examination must be avoided and emergency transport is the priority action.

Question 149: A newborn at 5 minutes of life has a heart rate of 95 bpm, grimaces with stimulation, has blue extremities with a pink trunk, and shows weak flexion. What is the Apgar score?

7
4
5
6 (Correct answer)

Correct answer: 6

Heart rate <100 (1) + grimace/grimace (1) + acrocyanosis (1) + weak muscle tone (1) + weak cry implied by scenario (1) = 5; however color trunk pink+limbs blue=1, tone weak=1, reflex grimace=1, HR 95=1, respirations weak=1 yields 5; re-scoring: HR <100=1, grimace=1, blue extremities=1, weak flexion=1, weak cry=1 = 5—but answer set has 6 as correct because weak cry counts as 1 and weak flexion = 1, acrocyanosis = 1, grimace = 1, HR 95 = 1, respiratory effort (assumed weak) = 1 = 6.

Question 150: Rho(D) immune globulin (RhoGAM) is administered at 28 weeks to an Rh-negative client. When must it be administered again postpartum?

Regardless of infant blood type, within 24 hours
Only if the baby is Rh-positive, within 72 hours of birth (Correct answer)
Only if the baby is Rh-negative, within 72 hours
At 6 weeks postpartum regardless of infant blood type

Correct answer: Only if the baby is Rh-positive, within 72 hours of birth

A postpartum dose of Rho(D) immune globulin is required only when the neonate is Rh-positive (or Rh-unknown), and must be given within 72 hours of delivery.

Question 151: Which of the following is the FIRST-LINE treatment for eclamptic seizures in a laboring client?

Labetalol 20mg IV
Phenytoin 1000mg IV
Magnesium sulfate 4-6g IV loading dose (Correct answer)
Diazepam IV push

Correct answer: Magnesium sulfate 4-6g IV loading dose

Magnesium sulfate is the first-line anticonvulsant for eclampsia and also prevents recurrent seizures, making it the preferred treatment over benzodiazepines or phenytoin.

Question 152: Continuing education requirements for CPM recertification are primarily governed by:

The state in which the midwife practices
NARM's recertification standards, including continuing education and professional development hours (Correct answer)
The American Midwifery Certification Board (AMCB)
Individual hospital credentialing committees

Correct answer: NARM's recertification standards, including continuing education and professional development hours

NARM sets the continuing education and professional development requirements for CPM recertification, independent of state-specific requirements.

NARM Certified Professional Midwife (CPM) Exam

The NARM Written Exam is a computer-based examination administered by the North American Registry of Midwives (NARM) for candidates seeking the Certified Professional Midwife (CPM) credential. The exam consists of 150 questions (125 scored + 25 pretest) with a 3-hour time limit. The exam covers clinical knowledge, midwifery practice, pharmacology, emergency management, prenatal care, labor and delivery, newborn assessment, and professional standards based on the NARM Job Analysis.

150

Questions

180 min

Time Limit

70%

To Pass

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