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

Question 1: Rho(D) immune globulin (RhoGAM) is administered at 28 weeks to an Rh-negative client. When must it be administered again postpartum?

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

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 2: 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
Amoxicillin 500 mg PO q8h
Clindamycin 900 mg IV q8h (Correct answer)
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 3: What newborn screening tests are done?

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

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

Multiple different tests screen for various conditions.

Question 4: The NARM Skills Assessment requires demonstration of competency in which of the following?

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

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

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

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

To assess fetal lung maturity
To determine the mother’s blood glucose levels
To measure the size of the fetal head
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 7: What is a non-stress test?

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

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

This test watches heart rate patterns during fetal movement.

Question 8: 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?

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

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

Prevent intraventricular hemorrhage by reducing fetal heart rate variability
Accelerate fetal lung maturation by stimulating surfactant production (Correct answer)
Reduce maternal fever that is triggering labor
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 10: What supplements are essential during pregnancy?

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

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

Several nutrients prevent defects and support fetal development.

Question 11: Which clinical finding best differentiates true labor from Braxton Hicks contractions?

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

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 12: Which finding indicates magnesium toxicity requiring immediate intervention?

Absent deep tendon reflexes (Correct answer)
Urinary output of 35 mL/hour
Respiratory rate of 14 breaths/minute
Serum magnesium level of 5 mEq/L

Correct answer: Absent deep tendon reflexes

Loss of deep tendon reflexes is the earliest clinical sign of magnesium toxicity and indicates serum levels approaching the toxic range (>7 mEq/L).

Question 13: A client at 36 weeks is prescribed nifedipine for tocolysis. Which side effect should the midwife anticipate and monitor?

Hyperkalemia and bradycardia
Maternal hypotension and reflex tachycardia (Correct answer)
Pulmonary edema and fluid overload
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 14: When administering Vitamin K (phytonadione) to a newborn, what is the correct intramuscular dose?

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

Correct answer: 1 mg

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

Question 15: Under the NARM Certified Professional Midwife (CPM) credential framework, which body is responsible for establishing the standards of competency that CPMs must demonstrate?

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

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 16: What is the golden hour after birth?

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

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

This critical first hour focuses on mother-baby contact.

Question 17: 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 18: 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?

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

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 19: What is the primary intervention for managing shoulder dystocia during vaginal delivery?

Using the McRoberts maneuver and applying suprapubic pressure (Correct answer)
Initiating neonatal resuscitation immediately
Administering oxytocin to stimulate contractions
Performing an emergency cesarean section

Correct answer: Using the McRoberts maneuver and applying suprapubic pressure

Shoulder dystocia is an obstetric emergency where the baby's shoulder gets stuck behind the mother's pubic bone after the head has delivered. The primary interventions involve specific maneuvers to dislodge the shoulder. The McRoberts maneuver (flexing the mother's thighs sharply to her abdomen) combined with suprapubic pressure (pressure applied above the pubic bone) are often the first and most effective steps to widen the pelvic outlet and facilitate delivery.

Question 20: 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 21: During a home birth, the midwife notes the umbilical cord prolapsing past the presenting part with the cervix fully dilated and vertex at +2 station. What is the priority action?

Place the client in Trendelenburg and transport immediately
Reposition the cord manually back into the uterus
Administer oxygen and prepare for immediate delivery
Apply firm upward pressure on the presenting part while calling 911 (Correct answer)

Correct answer: Apply firm upward pressure on the presenting part while calling 911

With cord prolapse at +2 station, the most effective immediate action is to manually elevate the presenting part to relieve cord compression while arranging emergency transport.

Question 22: What is the standard prenatal visit schedule for normal pregnancy?

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

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

Visit frequency increases as pregnancy progresses.

Question 23: Which assessment finding most reliably confirms that the placenta has separated before applying cord traction?

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

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

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

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 25: A postpartum client has a boggy uterus displaced to the right of midline 30 minutes after delivery. The most likely cause is:

Uterine atony secondary to retained placental fragments
Bladder distension (Correct answer)
Subinvolution
Normal uterine involution pattern

Correct answer: Bladder distension

A full bladder displaces the uterus laterally (most often to the right) and prevents effective uterine contraction, causing apparent uterine atony.

Question 26: What documentation is required per visit?

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

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

Comprehensive records are essential at every visit.

Question 27: A midwife administers carboprost (Hemabate) for uterine atony. Which condition is an absolute contraindication for this prostaglandin F2α analog?

Renal insufficiency
Asthma (Correct answer)
Hypertension
Hepatic failure

Correct answer: Asthma

Carboprost (Hemabate) is absolutely contraindicated in clients with active asthma because prostaglandin F2α causes bronchospasm and can precipitate a life-threatening asthma attack.

Question 28: 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
Document the refusal thoroughly, ensure the client understands the risk, and plan aggressive non-blood management strategies (Correct answer)
Agree verbally but arrange transfusion secretly if needed
Obtain a court order to transfuse if hemorrhage occurs

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 29: Normal newborn respiratory rate?

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

Correct answer: 30-60 breaths per minute

Newborns breathe much faster than adults.

Question 30: 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?

Intraosseous route
Umbilical vein catheter (Correct answer)
Endotracheal tube
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 31: When managing a third-degree perineal laceration, which structure differentiates a third-degree from a second-degree tear?

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

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 32: What is the appropriate initial management for a newborn presenting with respiratory distress immediately after birth?

Administer intravenous fluids
Perform a complete blood count (CBC) test
Start an intravenous antibiotic regimen
Provide positive pressure ventilation (Correct answer)

Correct answer: Provide positive pressure ventilation

For a newborn presenting with respiratory distress immediately after birth, the most critical initial intervention is to establish effective ventilation. If the newborn is not breathing or has ineffective respirations, positive pressure ventilation (PPV) is indicated to inflate the lungs and initiate gas exchange. This is a fundamental step in neonatal resuscitation to ensure adequate oxygenation and prevent hypoxia.

Question 33: 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
Begin chest compressions at a 3:1 ratio with PPV (Correct answer)
Continue PPV alone for another 30 seconds
Administer epinephrine via umbilical vein

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 34: What is the primary management goal during the active phase of labor?

Inducing labor if it is progressing slowly
Administering intravenous fluids to the mother
Providing continuous electronic fetal monitoring
Ensuring cervical dilation progresses at an appropriate rate (Correct answer)

Correct answer: Ensuring cervical dilation progresses at an appropriate rate

During the active phase of labor, the primary goal is to monitor and support the mother to ensure her cervix dilates efficiently and progressively, typically from 6 cm to 10 cm. This progression is crucial for the baby's descent and successful vaginal birth. Deviations from an appropriate rate may indicate complications and require intervention to ensure maternal and fetal safety.

Question 35: During a prenatal visit, a client discloses recreational marijuana use. The midwife's most appropriate response is to:

Ignore the disclosure to preserve the therapeutic relationship
Provide non-judgmental education on risks, document the disclosure, and continue supportive care (Correct answer)
Discharge the client from midwifery care
Report the client to child protective services immediately

Correct answer: Provide non-judgmental education on risks, document the disclosure, and continue supportive care

Non-judgmental counseling, education about fetal risks, and documentation are the appropriate professional responses; mandatory reporting thresholds vary by state and typically involve more serious concerns.

Question 36: 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?

Maternal fever and chorioamnionitis (Correct answer)
Fetal cardiac arrhythmia
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 37: A midwife attends a birth at which shoulder dystocia occurs. After successful delivery, she should:

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

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 38: Umbilical cord care for newborns?

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

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

Current evidence supports simple dry care.

Question 39: 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 40: A midwife administers erythromycin ophthalmic ointment to a newborn. What is the primary purpose of this prophylaxis?

Treatment of chemical conjunctivitis
Prevention of cytomegalovirus retinitis
Prevention of chlamydial and gonococcal conjunctivitis (Correct answer)
Treatment of herpes simplex keratitis

Correct answer: Prevention of chlamydial and gonococcal conjunctivitis

Erythromycin 0.5% ophthalmic ointment is applied to prevent ophthalmia neonatorum caused by Neisseria gonorrhoeae and Chlamydia trachomatis.

Question 41: 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
6 (Correct answer)
4
5

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 42: A client at 39 weeks reports decreased fetal movement. Kick count documentation shows 4 movements in 2 hours. The most appropriate response is:

Advise increased maternal caloric intake and recount tomorrow
Perform a non-stress test and consider biophysical profile if non-reactive (Correct answer)
Schedule a routine visit in 3 days
Reassure the client that 4 movements in 2 hours is within normal limits

Correct answer: Perform a non-stress test and consider biophysical profile if non-reactive

Fewer than 10 movements in 2 hours (or fewer than 6 in some protocols) is a threshold requiring electronic fetal monitoring to evaluate fetal status.

Question 43: 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 state medical board, since CPMs operate under physician oversight
The local health department
No entity has jurisdiction in unlicensed states

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

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)
NARM certification guarantees the legal right to practice in every U.S. state
They are identical processes administered by the same authority

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

Placing the client in knee-chest position
Elevating the presenting part manually
Pushing the cord back through the cervix (Correct answer)
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 46: When should first breastfeeding occur?

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

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

Early initiation promotes successful lactation.

Question 47: 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 standardized hospital-style progress note regardless of birth setting
A signed waiver from the client for each visit
A billing invoice with procedure codes

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 48: A client at 28 weeks gestation presents with headache, visual changes, epigastric pain, and a blood pressure of 162/110. Laboratory results show platelets 88,000 and ALT 3x normal. What syndrome is present?

Acute fatty liver of pregnancy
Gestational hypertension
Severe preeclampsia without features
HELLP syndrome (Correct answer)

Correct answer: HELLP syndrome

HELLP syndrome is characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets; thrombocytopenia below 100,000 and elevated transaminases confirm this diagnosis.

Question 49: 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:

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

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 50: 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 51: What is neonatal hypoglycemia?

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

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

Low blood sugar requires prompt treatment.

Question 52: A primigravida at 41+3 weeks has a Bishop score of 3. Which cervical ripening method is most appropriate prior to induction?

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

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 53: A postpartum client on day 3 reports increased bleeding after ambulating. What is the most appropriate initial action?

Administer oxytocin 10 units IM immediately without further assessment
Arrange immediate emergency transport without further evaluation
Assess fundal tone, quantify blood loss, and evaluate vital signs (Correct answer)
Reassure her that increased activity normally increases lochia flow

Correct answer: Assess fundal tone, quantify blood loss, and evaluate vital signs

Assessment of uterine tone, quantification of blood loss, and vital sign evaluation must precede any intervention to differentiate normal lochia variation from early postpartum hemorrhage.

Question 54: What is the NARM certification process?

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

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

Multiple components are required for certification.

Question 55: Which of the following best describes cultural humility in midwifery practice?

Delegating cultural considerations to a cultural liaison
Learning a fixed set of cultural practices for each patient population served
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

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

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

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 57: What is a nuchal cord?

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

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

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

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 59: 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?

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

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 60: 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 61: What is a biophysical profile?

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

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

Multiple aspects of fetal health are evaluated simultaneously.

Question 62: When should midwife-to-physician transfer occur?

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

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

Certain complications require medical intervention.

Question 63: When a midwife transfers care of a laboring client to a hospital, which action best supports continuity of care?

Providing a verbal and written report including prenatal history, labor progress, medications given, and reason for transfer (Correct answer)
Leaving all care decisions to the hospital team without interfering
Sending only the prenatal chart and waiting in the lobby
Calling the hospital after transfer to provide a report

Correct answer: Providing a verbal and written report including prenatal history, labor progress, medications given, and reason for transfer

A thorough verbal and written handoff including prenatal history, labor course, interventions, and transfer reason ensures safe continuity of care at the receiving facility.

Question 64: What warrants emergency transport from home birth?

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

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

Certain emergencies require hospital-level resources.

Question 65: Which of the following is a common sign of postpartum hemorrhage?

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

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 66: 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)
Steady-state plasma levels are achieved within 5 minutes of starting infusion
Oxytocin crosses the placenta and directly stimulates fetal myometrium

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 67: What is gestational diabetes screening?

A permanent diabetes test
Glucose tolerance test at 24-28 weeks for diabetes developing during pregnancy (Correct answer)
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 68: Which of the following is the FIRST-LINE treatment for eclamptic seizures in a laboring client?

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

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 69: 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?

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

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

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

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

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

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 72: 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 73: 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?

Assess vital signs and call for emergency transport (Correct answer)
Perform a sterile vaginal exam to assess cervical dilation
Apply fundal pressure to determine placental location
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 74: Which screening tool is most widely validated and recommended for postpartum depression screening in midwifery practice?

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

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 75: Which of the following best describes the concept of informed consent in midwifery practice?

Providing the patient with a brief overview of the procedure without detailed information
Obtaining a signed consent form for all procedures regardless of the patient's understanding
Assuming consent based on the patient's general agreement to care
Ensuring the patient understands the risks, benefits, and alternatives to a procedure or treatment before agreeing to it (Correct answer)

Correct answer: Ensuring the patient understands the risks, benefits, and alternatives to a procedure or treatment before agreeing to it

Informed consent is a fundamental ethical and legal principle in healthcare, requiring that a patient receives comprehensive information about their medical condition, proposed treatments, and available alternatives. This includes understanding the risks, benefits, and potential side effects of any procedure or treatment. The goal is to empower the patient to make an autonomous and well-reasoned decision about their care, rather than simply signing a form or receiving a brief overview.

Question 76: What does fundal height measure?

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

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

This external measurement tracks pregnancy growth.

Question 77: Purpose of peer review in midwifery?

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

Correct answer: Evaluate practice, promote quality, maintain standards

Professional evaluation improves practice quality.

Question 78: 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 79: Which description best characterizes normal lochia rubra?

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

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

To conform to a specific cultural norm for all patients
To avoid addressing any cultural differences in care
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

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 81: Which intervention is most effective in preventing postpartum hemorrhage?

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

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

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

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 83: Purpose of newborn metabolic screen?

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

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

Early detection enables treatment before irreversible damage.

Question 84: How to distinguish true from false labor?

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

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

Progressive cervical change is the key difference.

Question 85: What is the primary purpose of a midwife maintaining a signed, written informed consent document for planned home birth?

To limit the midwife's liability regardless of standard of care
To satisfy insurance billing requirements
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)

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 86: Signs of neonatal respiratory distress?

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

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

Multiple visible signs show breathing difficulty.

Question 87: When counseling a client about Group B Streptococcus (GBS) prophylaxis, which scenario requires intrapartum antibiotic administration?

GBS-positive status with prior cesarean delivery at 40 weeks
GBS-negative culture at 35 weeks with rupture of membranes at 38 weeks
GBS-unknown status with elective cesarean at 39 weeks with intact membranes
GBS-positive vaginal/rectal culture at 36 weeks with planned vaginal delivery (Correct answer)

Correct answer: GBS-positive vaginal/rectal culture at 36 weeks with planned vaginal delivery

A client with a GBS-positive culture who plans a vaginal delivery requires intrapartum IV penicillin G (or appropriate alternative) to prevent early-onset neonatal GBS disease.

Question 88: 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 89: A postpartum woman on day 5 is found to have a blood pressure of 154/98 mmHg with a headache. What condition should the midwife most suspect?

Newly diagnosed essential hypertension unrelated to pregnancy
Anxiety-related white coat hypertension
Normal postpartum physiological blood pressure variation
Postpartum preeclampsia requiring immediate evaluation and management (Correct answer)

Correct answer: Postpartum preeclampsia requiring immediate evaluation and management

Postpartum preeclampsia can develop up to 6 weeks after delivery; a BP ≥140/90 mmHg with symptoms such as headache requires urgent evaluation and treatment.

Question 90: Which is the first action a midwife should take if a patient experiences a postpartum hemorrhage?

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

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 91: 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
Lorazepam 4mg IV push
Magnesium sulfate 4-6g IV over 15-20 minutes (Correct answer)
Diazepam 10mg IM

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

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

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 93: 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)
Mild acrocyanosis at 5 minutes of age
Oxygen saturation of 99% on the right hand

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 94: A client reports she took metformin throughout pregnancy for type 2 diabetes. Which neonatal complication should the midwife monitor for immediately after birth?

Hypoglycemia (Correct answer)
Respiratory alkalosis
Hypercalcemia
Polycythemia

Correct answer: Hypoglycemia

Neonates born to mothers on metformin or insulin are at risk for hypoglycemia due to fetal hyperinsulinism responding to maternal glucose levels.

Question 95: What is Group B Strep screening?

Strep throat test
STI test
Test at 35-37 weeks for bacteria that could infect baby during birth (Correct answer)
Blood type 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 96: Why is vitamin K given to newborns?

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

Correct answer: Prevents hemorrhagic disease by supporting clotting

Newborns cannot produce adequate clotting factors.

Question 97: Which medication is commonly used to manage postpartum hemorrhage due to uterine atony?

Oxytocin (Pitocin) (Correct answer)
Methylergometrine (Methergine)
Betamethasone
Magnesium sulfate

Correct answer: Oxytocin (Pitocin)

Oxytocin is the first-line uterotonic medication used to prevent and treat postpartum hemorrhage, particularly when caused by uterine atony (a boggy, relaxed uterus). It works by stimulating strong, sustained contractions of the uterine muscle, which helps to compress blood vessels and reduce bleeding. Its rapid action and effectiveness make it a critical intervention in managing this obstetric emergency.

Question 98: CPM scope of practice limitations?

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

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

This credential covers normal pregnancies with clear boundaries.

Question 99: What is active management of third stage?

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

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

Three interventions reduce postpartum hemorrhage risk.

Question 100: Signs of neonatal jaundice?

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

Correct answer: Yellow skin and eyes from elevated bilirubin

This condition causes characteristic color changes.

Question 101: After repair of a second-degree perineal laceration, which perineal care instruction is most appropriate?

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

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 102: 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?

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

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 103: Which of the following represents the correct order of cardinal movements of labor?

Engagement, descent, internal rotation, flexion, extension, external rotation, expulsion
Engagement, flexion, descent, internal rotation, extension, external rotation, expulsion
Descent, engagement, flexion, extension, internal rotation, external rotation, expulsion
Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion (Correct answer)

Correct answer: Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion

The seven cardinal movements proceed as: engagement → descent → flexion → internal rotation → extension → external rotation (restitution) → expulsion.

Question 104: Which postpartum finding would most raise the midwife's suspicion for deep vein thrombosis (DVT)?

Generalized fatigue and difficulty sleeping at 2 weeks postpartum
Bilateral varicose veins that persist from pregnancy
Unilateral calf pain, warmth, and swelling with low-grade fever (Correct answer)
Bilateral mild ankle edema at 1 week postpartum

Correct answer: Unilateral calf pain, warmth, and swelling with low-grade fever

Unilateral calf pain, warmth, and swelling are classic signs of DVT; postpartum women are at elevated thromboembolism risk due to hypercoagulable state and reduced mobility.

Question 105: What are preeclampsia warning signs?

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

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

This condition involves hypertension with multiple symptoms.

Question 106: 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?

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

Correct answer: Sertraline (Zoloft)

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

Question 107: What is the correct technique for bimanual compression of the uterus to manage postpartum hemorrhage from uterine atony?

One hand inside the vagina forming a fist, other hand compressing the uterus abdominally from the front and back (Correct answer)
Both hands placed on the abdomen compressing the uterus laterally
One fist inside the uterus, other hand pushing the fundus downward externally
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 108: Proper newborn resuscitation steps?

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

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

A stepwise approach starts with simple interventions.

Question 109: When performing the Rubin II maneuver for shoulder dystocia, in which direction is pressure applied to the anterior shoulder?

Toward the fetal face (adduction) (Correct answer)
Upward toward the pubic symphysis
Away from the fetal face (abduction)
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 110: Continuing education requirements for CPM recertification are primarily governed by:

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

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.

Question 111: During active labor, late decelerations are observed on the fetal monitor with each contraction. The initial nursing/midwifery intervention is to:

Reposition client to lateral decubitus and administer IV fluid bolus (Correct answer)
Prepare for immediate cesarean delivery
Perform amnioinfusion
Increase oxytocin infusion rate

Correct answer: Reposition client to lateral decubitus and administer IV fluid bolus

Late decelerations suggest uteroplacental insufficiency; repositioning improves uterine perfusion and IV fluids increase maternal cardiac output as first-line interventions.

Question 112: A postpartum client at day 3 calls reporting a temperature of 100.6°F (38.1°C), tender uterus, and foul-smelling lochia. What is the midwife's priority action?

Recommend a sitz bath and over-the-counter pain relievers
Assess urgently, as these findings suggest endometritis requiring prompt evaluation and likely antibiotic treatment (Correct answer)
Reassure the client that mild fever is normal in the first week postpartum
Advise increased fluid intake and call back in 24 hours

Correct answer: Assess urgently, as these findings suggest endometritis requiring prompt evaluation and likely antibiotic treatment

Fever, uterine tenderness, and foul lochia are classic signs of endometritis, a serious infection requiring urgent evaluation and treatment.

Question 113: Normal weight loss in breastfed newborns?

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

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

Initial weight loss is normal and temporary.

Question 114: What is the recommended management for a patient presenting with a prolonged rupture of membranes (PROM) and signs of infection?

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

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 115: Normal newborn heart rate?

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

Correct answer: 120-160 bpm

A newborns heart beats much faster than an adults.

Question 116: Legal status of CPMs in the US?

Federal law governs all
Varies by state from full licensure to prohibition (Correct answer)
Illegal everywhere
Licensed in all 50 states

Correct answer: Varies by state from full licensure to prohibition

The legal framework varies significantly by state.

Question 117: What is intermittent auscultation?

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

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

Periodic listening assesses fetal well-being during labor.

Question 118: A midwife's client at 39 weeks is GBS-positive and declines IV antibiotics in labor. The midwife should:

Refuse to attend the birth until the client agrees to antibiotics
Administer antibiotics without the client's knowledge for the newborn's safety
Transfer care immediately to a hospital-based provider
Provide thorough counseling on risks to the newborn, document the informed refusal, and attend the birth with enhanced newborn monitoring (Correct answer)

Correct answer: Provide thorough counseling on risks to the newborn, document the informed refusal, and attend the birth with enhanced newborn monitoring

The midwife must respect autonomy, ensure the client is fully informed of neonatal GBS risks, document the refusal, and plan enhanced surveillance for the newborn.

Question 119: What is shoulder dystocia?

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

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

This emergency occurs when the baby gets stuck during delivery.

Question 120: Which of the following is the correct technique for performing Leopold's maneuver to determine fetal lie?

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

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 121: What is postpartum hemorrhage?

Labor bleeding
Any post-delivery bleeding
First trimester 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 122: 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:

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

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 123: Which postpartum complication is defined as failure of the uterus to return to its pre-pregnancy size at the expected rate?

Uterine subinvolution (Correct answer)
Uterine prolapse
Retained placental fragment only
Postpartum hemorrhage

Correct answer: Uterine subinvolution

Subinvolution is the failure of normal uterine involution; it is often caused by retained placental fragments, uterine infection, or uterine fibroids, and presents with a uterus larger than expected for the postpartum day.

Question 124: A G3P2 client at 41 weeks with a previous cesarean delivery presents with spontaneous onset of labor. During active phase, she reports a sudden pop followed by cessation of contractions and worsening abdominal pain. What is the priority action?

Perform an amniotomy
Reassess in 30 minutes
Call 911 and prepare for immediate transport (Correct answer)
Augment labor with oxytocin

Correct answer: Call 911 and prepare for immediate transport

Sudden cessation of contractions with worsening abdominal pain in a VBAC client is a classic sign of uterine rupture requiring immediate surgical intervention.

Question 125: Which herbal supplement is CONTRAINDICATED in pregnancy due to its uterotonic properties?

Blue cohosh (Caulophyllum thalictroides) (Correct answer)
Chamomile tea
Ginger (Zingiber officinale) in food amounts
Red raspberry leaf tea

Correct answer: Blue cohosh (Caulophyllum thalictroides)

Blue cohosh contains caulosaponin and caulophyllosaponin, which have uterotonic and vasoconstrictive effects and are associated with neonatal heart failure.

Question 126: Which document is crucial for ensuring that a midwife's professional and ethical responsibilities are clearly defined?

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

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

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

Correct answer: Schedule III

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

Question 128: A midwife is managing a postpartum hemorrhage unresponsive to oxytocin. Which second-line uterotonic is appropriate, but is CONTRAINDICATED in clients with hypertension?

Carboprost tromethamine (Hemabate) 250 mcg IM
Methylergonovine (Methergine) 0.2 mg IM (Correct answer)
Tranexamic acid 1 g IV
Misoprostol 800 mcg rectal

Correct answer: Methylergonovine (Methergine) 0.2 mg IM

Methylergonovine (Methergine) causes vasoconstriction and is contraindicated in hypertensive clients as it can precipitate severe hypertension and stroke.

Question 129: 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?

4
2
3 (Correct answer)
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 130: A midwife learns that a colleague is practicing outside her approved scope by routinely performing vacuum-assisted deliveries at home births. The midwife should:

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
Assume the colleague has special training and take no action

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 131: 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 132: Which finding during a newborn's initial assessment is a normal variant that requires no intervention?

Respiratory rate of 68 breaths per minute at 2 hours of life
Absent femoral pulses bilaterally
Epstein's pearls on the hard palate (Correct answer)
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 133: A midwife is considering accepting a home birth client who is a grand multipara (gravida 7, para 6). Her most important next step is:

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

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 134: Which statement best distinguishes postpartum blues from postpartum depression?

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

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 135: What is Rh factor importance in pregnancy?

Rh-negative mothers may develop antibodies against Rh-positive babies, requiring RhoGAM (Correct answer)
A prenatal test type
Blood sugar measure
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 136: When managing a shoulder dystocia, which maneuver is performed first after standard McRoberts positioning and suprapubic pressure fail?

Delivery of the posterior arm
Deliberate clavicle fracture
Zavanelli maneuver (cephalic replacement)
Rubin II maneuver (internal rotation of anterior shoulder) (Correct answer)

Correct answer: Rubin II maneuver (internal rotation of anterior shoulder)

After McRoberts and suprapubic pressure, internal rotational maneuvers such as Rubin II or Woods screw are the recommended next step before attempting posterior arm delivery.

Question 137: Which statement about tranexamic acid (TXA) in postpartum hemorrhage is accurate based on the WOMAN trial?

TXA is contraindicated after cesarean section
TXA replaces uterotonic therapy as first-line treatment
TXA given within 3 hours of postpartum hemorrhage onset reduces death from bleeding (Correct answer)
TXA is most effective when given more than 3 hours after birth onset

Correct answer: TXA given within 3 hours of postpartum hemorrhage onset reduces death from bleeding

The WOMAN trial showed that tranexamic acid reduces death due to bleeding when administered within 3 hours of postpartum hemorrhage onset, without increasing thromboembolic events.

Question 138: What is the purpose of administering Rho(D) immunoglobulin (RhoGAM) to a Rh-negative mother after delivery?

To prevent the development of Rh incompatibility in future pregnancies (Correct answer)
To treat fetal distress during labor
To manage preterm labor
To prevent postpartum hemorrhage

Correct answer: To prevent the development of Rh incompatibility in future pregnancies

Rho(D) immunoglobulin (RhoGAM) is administered to Rh-negative mothers after delivering an Rh-positive baby, or after other events like miscarriage or abortion. Its purpose is to prevent the mother's immune system from developing antibodies against Rh-positive red blood cells. If these antibodies were to form, they could attack the red blood cells of a future Rh-positive fetus, leading to severe complications like hemolytic disease of the newborn.

Question 139: What are ectopic pregnancy signs?

Increased appetite
Morning sickness
Normal symptoms
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 140: What is the Apgar score?

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

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

Five newborn parameters are scored immediately after birth.

Question 141: A newborn's blood glucose at 1 hour of life is 38 mg/dL and the infant is asymptomatic. The best initial management is:

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

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 142: What is meconium-stained fluid?

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

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 143: What is cervical insufficiency?

Cesarean complication
An infection type
Normal late pregnancy
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 144: What are the three stages of labor?

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

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

Labor has three distinct stages from start to completion.

Question 145: Obligation when client refuses recommended care?

Report to authorities
Override wishes
Refuse to continue care
Respect autonomy, ensure understanding of risks, document refusal, continue care (Correct answer)

Correct answer: Respect autonomy, ensure understanding of risks, document refusal, continue care

Client autonomy must be respected.

Question 146: 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:

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

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 147: Client confidentiality obligations?

Optional
Only medical records
All health info confidential, shared only with consent or as legally required (Correct answer)
Share with anyone

Correct answer: All health info confidential, shared only with consent or as legally required

Health information privacy is fundamental.

Question 148: A client delivers a 4,200g infant and subsequently develops a postpartum hemorrhage unresponsive to oxytocin and uterine massage. Which uterotonic should be considered next?

Ergotamine
Methylergonovine (Methergine)
Misoprostol 200mcg oral
Carboprost (Hemabate) (Correct answer)

Correct answer: Carboprost (Hemabate)

Carboprost (Hemabate), a prostaglandin F2-alpha analog, is a second-line uterotonic for atony-related PPH unresponsive to oxytocin; it is contraindicated in asthma.

Question 149: 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 150: A client at 39 weeks gestation presents with sudden onset of severe abdominal pain, rigid abdomen, and fetal heart tones that drop from 140 to 60 bpm. What is the most likely diagnosis?

Cord prolapse
Severe preeclampsia
Uterine rupture (Correct answer)
Placenta previa

Correct answer: Uterine rupture

Uterine rupture presents with sudden severe abdominal pain, a rigid abdomen, and acute fetal bradycardia due to fetal distress from disrupted placental perfusion.

Question 151: What is the generally recommended minimum interval before resuming vaginal intercourse following an uncomplicated vaginal birth?

2 weeks postpartum once lochia has stopped
Only after the return of menstruation regardless of time elapsed
3 months postpartum to ensure complete uterine involution
4–6 weeks postpartum to allow perineal healing and cervical closure (Correct answer)

Correct answer: 4–6 weeks postpartum to allow perineal healing and cervical closure

Most providers recommend waiting at least 4–6 weeks postpartum before resuming intercourse to allow adequate healing of perineal tissues and cervical closure, reducing infection risk.

Question 152: 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?

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

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.

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

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds