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Cambodia Midwifery Exit Exam study materials
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Cambodia Midwifery Exit Exam practice questions

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Question 1Antenatal Care and Normal Pregnancy

A woman at 12 weeks' gestation attends her first antenatal visit in Cambodia. Which routine investigation should be offered at this visit to detect anaemia?

  1. Oral glucose tolerance test
  2. Haemoglobin measurement Correct answer.
  3. Cervical cytology
  4. Ultrasound for fetal anomaly

Explanation

Haemoglobin estimation is a standard first-visit antenatal test because anaemia is common in pregnancy and is associated with low birth weight and maternal morbidity. It establishes a baseline for later comparison and guides iron and folate supplementation. Glucose tolerance testing and detailed anomaly scanning are done later in pregnancy, not at the booking visit.

Question 2Antenatal Care and Normal Pregnancy

A pregnant woman in her first trimester asks how many additional kilocalories she needs each day. What is the most appropriate advice?

  1. No extra calories are needed in the first trimester Correct answer.
  2. An extra 1000 kcal daily throughout pregnancy
  3. An extra 340 kcal daily from the first week
  4. An extra 500 kcal daily from conception

Explanation

Energy requirements do not increase during the first trimester; the fetus is small and maternal fat stores are being laid down efficiently. Additional energy, roughly 340 kcal per day in the second trimester and 450 kcal per day in the third, is needed only later. Advising extra food too early contributes to excessive gestational weight gain without benefit.

Question 3Antenatal Care and Normal Pregnancy

Which prophylactic supplement is routinely recommended for all pregnant women in Cambodia to reduce the risk of neural tube defects?

  1. Folic acid Correct answer.
  2. Calcium carbonate
  3. Vitamin A high dose
  4. Vitamin K

Explanation

Periconceptional folic acid supplementation reduces the incidence of neural tube defects such as spina bifida and anencephaly. It is most effective when started before conception and continued through the first trimester. Calcium and vitamin K address different needs, and high-dose vitamin A in early pregnancy carries teratogenic risk.

Question 4Antenatal Care and Normal Pregnancy

At what gestational age is a woman's expected date of delivery calculated using Naegele's rule, counting from the first day of her last menstrual period?

  1. 252 days, or 36 weeks
  2. 266 days, or 38 weeks
  3. 294 days, or 42 weeks
  4. 280 days, or 40 weeks Correct answer.

Explanation

Naegele's rule adds 280 days, or 40 weeks, to the first day of the last menstrual period to estimate the expected date of delivery. This assumes a regular 28-day cycle with ovulation around day 14. The estimate should be adjusted if the cycle is irregular or if early ultrasound gives a different dating.

Question 5Antenatal Care and Normal Pregnancy

A woman at 10 weeks' gestation reports mild nausea and vomiting but is able to eat and drink and is not dehydrated. What is the most appropriate initial management?

  1. Immediate hospital admission for intravenous fluids
  2. Reassurance, small frequent meals, and avoidance of fatty foods Correct answer.
  3. Routine termination counselling
  4. High-dose corticosteroids

Explanation

Mild nausea and vomiting of pregnancy is common and usually managed with dietary measures such as small frequent dry meals, ginger, and avoiding strong odours. Admission for intravenous rehydration is reserved for women who cannot keep fluids down or show signs of dehydration. Corticosteroids are a late-line option for severe hyperemesis only.

Question 6Antenatal Care and Normal Pregnancy

Which finding on routine antenatal examination is a normal physiological change of pregnancy rather than a sign of disease?

  1. Haemoglobin of 10.8 g/dL at 30 weeks Correct answer.
  2. Fasting blood glucose of 7.5 mmol/L at 26 weeks
  3. Blood pressure of 150/100 mmHg at 32 weeks
  4. Proteinuria of 2+ at 28 weeks

Explanation

Physiological haemodilution in pregnancy lowers haemoglobin concentration, so values around 10.5 to 11 g/dL in the second half of pregnancy are expected and not diagnostic of anaemia. Hypertension, hyperglycaemia, and significant proteinuria are all abnormal and require assessment. Distinguishing normal physiology from pathology prevents unnecessary intervention.

Question 7Antenatal Care and Normal Pregnancy

A woman at 34 weeks' gestation reports that her baby's movements have reduced compared with previous days. What is the most appropriate action?

  1. Arrange immediate assessment of fetal wellbeing Correct answer.
  2. Ask her to return in two weeks if movements remain reduced
  3. Advise her to drink cold water and ignore the change
  4. Reassure her that movements naturally decrease near term

Explanation

Reduced fetal movements can be an early warning sign of fetal compromise and should prompt prompt assessment of fetal wellbeing, including auscultation or cardiotocography and ultrasound as available. Movements do not normally decrease in late pregnancy. Delaying assessment risks stillbirth.

Question 8Antenatal Care and Normal Pregnancy

Which statement best describes the purpose of the antenatal card or home-based record given to a pregnant woman in Cambodia?

  1. It allows continuity of care when the woman is seen by different providers Correct answer.
  2. It replaces the need for clinical examination
  3. It is kept at the health centre and never given to the woman
  4. It is used only for billing purposes

Explanation

The antenatal card is a portable record that carries information on gestational age, test results, risk factors, and care given, so any provider can continue care safely. It supports referral and emergency decision-making when the woman presents at a different facility. It supplements but never replaces clinical assessment.

Question 9Antenatal Care and Normal Pregnancy

A woman at 26 weeks' gestation has a haemoglobin of 8.2 g/dL with a normal mean cell volume. Which is the most appropriate next step?

  1. Treat with oral iron and folate and recheck haemoglobin in about four weeks Correct answer.
  2. Arrange immediate blood transfusion
  3. Reassure her that this value is normal in pregnancy
  4. Withhold iron until after delivery

Explanation

A haemoglobin of 8.2 g/dL indicates moderate anaemia in pregnancy and is usually due to iron deficiency, so oral iron with folate is the first-line treatment. Rechecking after about four weeks confirms response and adherence. Transfusion is reserved for severe anaemia with compromise or near term.

Question 10Antenatal Care and Normal Pregnancy

A woman at 32 weeks has a blood pressure of 145/95 mmHg on two occasions four hours apart, with no proteinuria and no symptoms. How should this be classified?

  1. Gestational hypertension Correct answer.
  2. Severe pre-eclampsia
  3. Chronic hypertension
  4. Normal pregnancy blood pressure

Explanation

New hypertension arising after 20 weeks without proteinuria or other organ dysfunction is classified as gestational hypertension. It requires close monitoring because a proportion of women progress to pre-eclampsia. Severe pre-eclampsia requires much higher pressures or evidence of organ involvement, and chronic hypertension predates 20 weeks.

Question 11Antenatal Care and Normal Pregnancy

A woman at 30 weeks has a symphysis-fundal height of 24 cm. What is the most appropriate interpretation?

  1. The measurement is normal for this gestation
  2. The measurement indicates a multiple pregnancy
  3. The measurement confirms macrosomia
  4. The measurement is smaller than expected and fetal growth should be assessed Correct answer.

Explanation

Between 24 and 36 weeks, symphysis-fundal height in centimetres roughly equals gestational age in weeks, so 24 cm at 30 weeks is about 6 cm below expectation. This warrants assessment of fetal growth, amniotic fluid, and dating. A lagging measurement can reflect growth restriction, oligohydramnios, or inaccurate dates.

Question 12Antenatal Care and Normal Pregnancy

Which pregnant woman has a risk factor that warrants referral for delivery at a facility with comprehensive emergency obstetric care?

  1. A woman with two previous caesarean sections Correct answer.
  2. A woman with mild nausea at 9 weeks
  3. A woman with a singleton pregnancy at 38 weeks and no complications
  4. A woman in her second pregnancy with a previous normal vaginal birth

Explanation

Two or more previous caesarean sections increase the risk of placenta accreta spectrum and uterine rupture, so delivery should be planned where blood products and surgical teams are available. Uncomplicated multiparity and mild early symptoms do not require referral. Risk assessment at each antenatal visit determines the appropriate birth setting.

Question 13Antenatal Care and Normal Pregnancy

A woman at 16 weeks reports no danger signs but has never had a tetanus toxoid vaccination. How should tetanus immunisation be started?

  1. Wait until the third trimester to begin
  2. Give the first dose now and complete the schedule at recommended intervals Correct answer.
  3. Avoid vaccination during pregnancy
  4. Give a single dose only and consider the woman protected

Explanation

Tetanus toxoid vaccination is safe in pregnancy and should be started at the first contact, with subsequent doses given at the recommended intervals to achieve protective antibody levels for mother and newborn. Waiting until late pregnancy risks incomplete protection. A single dose does not provide adequate protection.

Question 14Antenatal Care and Normal Pregnancy

A woman at 24 weeks has a midstream urine culture growing more than 100,000 colony-forming units per mL of E. coli, but she has no urinary symptoms. What is the appropriate management?

  1. Withhold treatment because she is asymptomatic
  2. Treat with an appropriate antibiotic based on sensitivity Correct answer.
  3. Repeat the culture only after delivery
  4. Advise increased fluid intake alone

Explanation

Asymptomatic bacteriuria in pregnancy is treated because it progresses to pyelonephritis in a substantial proportion of untreated women and is associated with preterm birth. Treatment is guided by culture and sensitivity, choosing an agent safe in pregnancy. Simply increasing fluids does not eradicate the bacteria.

Question 15Antenatal Care and Normal Pregnancy

A woman at 28 weeks has a random blood glucose of 9.8 mmol/L and a history of a macrosomic baby. What is the most appropriate next step?

  1. Arrange diagnostic testing for gestational diabetes Correct answer.
  2. Start insulin without further testing
  3. Reassure her that random glucose is not useful
  4. Repeat the test after delivery

Explanation

A random glucose above threshold plus a history of macrosomia raises strong suspicion of gestational diabetes, so formal diagnostic testing with an oral glucose tolerance test is indicated. Confirmation is needed before starting treatment such as insulin. Deferring evaluation until after delivery misses the opportunity to reduce perinatal complications.

Question 16Antenatal Care and Normal Pregnancy

A woman at 36 weeks has a fetus in a transverse lie. What is the most important implication for birth planning?

  1. She can plan a normal vaginal birth at a health centre
  2. She should be advised to deliver at home
  3. She needs referral for assessment because vaginal birth is not possible in a persistent transverse lie Correct answer.
  4. The lie will correct itself in all cases

Explanation

A persistent transverse lie at term cannot deliver vaginally and carries a risk of cord prolapse and obstructed labour if membranes rupture. The woman should be referred to a facility with caesarean capability for assessment and planning. Assuming spontaneous correction or planning a home birth is unsafe.

Question 17Antenatal Care and Normal Pregnancy

A woman at 22 weeks reports a sudden gush of fluid from the vagina. On examination there is pooling of fluid in the vagina. What is the most appropriate action?

  1. Perform a pelvic examination to check dilatation at home
  2. Refer for hospital assessment and management of preterm prelabour rupture of membranes Correct answer.
  3. Advise her to return at 28 weeks
  4. Reassure her that this is normal vaginal discharge

Explanation

Pooling of fluid in the vagina at 22 weeks suggests preterm prelabour rupture of membranes, which requires hospital assessment for confirmation, infection screening, and counselling. Digital vaginal examination should be avoided before assessment because it introduces infection. Expectant management at home is unsafe at this gestation.

Question 18Antenatal Care and Normal Pregnancy

Which antenatal intervention has been shown to reduce the risk of pre-eclampsia in women at high risk?

  1. Low-dose aspirin started before 16 weeks Correct answer.
  2. Bed rest for the whole pregnancy
  3. Routine diuretic therapy
  4. Routine high-dose vitamin C

Explanation

Low-dose aspirin started in early pregnancy reduces the incidence of pre-eclampsia in women at high risk by interfering with platelet thromboxane production. It is recommended for women with risk factors such as previous pre-eclampsia or chronic hypertension. Bed rest and diuretics have no proven benefit and may cause harm.

Question 19Antenatal Care and Normal Pregnancy

A woman at 18 weeks has a mid-upper arm circumference suggesting undernutrition and reports food insecurity. Which counselling approach is most appropriate?

  1. Recommend expensive imported supplements only
  2. Advise on affordable locally available protein- and iron-rich foods and refer for nutrition support Correct answer.
  3. Tell her diet does not affect pregnancy outcome
  4. Advise her to skip meals to control weight gain

Explanation

Maternal undernutrition is associated with low birth weight and maternal anaemia, so counselling should focus on affordable, locally available nutrient-dense foods and linkage to nutrition support programmes. Skipping meals worsens the deficit. Diet quality clearly influences pregnancy outcomes.

Question 20Antenatal Care and Normal Pregnancy

A woman at 38 weeks has a haemoglobin of 11.5 g/dL and a blood pressure of 110/70 mmHg. She asks about the warning signs that should make her come to the health facility immediately. Which set of signs is most appropriate to teach?

  1. Increased appetite and fetal hiccups
  2. Vaginal bleeding, severe headache, blurred vision, and reduced fetal movements Correct answer.
  3. Mild ankle swelling and backache
  4. Occasional heartburn and constipation

Explanation

Danger signs in late pregnancy include vaginal bleeding, severe headache, visual disturbance, and reduced fetal movements, all of which may indicate abruption, pre-eclampsia, or fetal compromise. Teaching women these signs promotes early care-seeking. Common minor discomforts do not require emergency attendance.

Question 21Antenatal Care and Normal Pregnancy

A woman at 13 weeks has a body mass index of 35 kg/m2. Which antenatal consideration is most important?

  1. Screening for gestational diabetes and counselling on appropriate weight gain Correct answer.
  2. Routine induction of labour at 34 weeks
  3. Reassurance that obesity carries no additional risk
  4. Advising a weight-loss diet during pregnancy

Explanation

Maternal obesity increases the risk of gestational diabetes, hypertensive disorders, macrosomia, and caesarean birth, so early screening and counselling on appropriate gestational weight gain are priorities. Weight-loss dieting in pregnancy is not advised. Induction timing is decided later based on individual risk.

Question 22Antenatal Care and Normal Pregnancy

A woman at 20 weeks is Rh-negative and the father is Rh-positive. What is the current approach to anti-D prophylaxis?

  1. Give anti-D immunoglobulin at appropriate gestational ages and after sensitising events Correct answer.
  2. Give anti-D only after delivery
  3. Give anti-D only if the father is also Rh-negative
  4. Withhold anti-D unless the woman has bleeding

Explanation

Rh-negative unsensitised women receive anti-D immunoglobulin both as routine antenatal prophylaxis and after potentially sensitising events such as bleeding or invasive procedures. This prevents maternal antibody formation that could harm future pregnancies. Withholding until delivery misses opportunities to prevent sensitisation.

Question 23Antenatal Care and Normal Pregnancy

A woman at 12 weeks has a blood pressure of 160/100 mmHg and a history of hypertension before pregnancy. How should her antenatal care be planned?

  1. Reassure her that blood pressure falls in pregnancy
  2. Stop all antihypertensive medication immediately
  3. Manage as chronic hypertension with baseline renal and cardiac assessment and planned specialist follow-up Correct answer.
  4. Manage as gestational hypertension diagnosed at 12 weeks

Explanation

Hypertension present before 20 weeks is chronic hypertension, which requires baseline assessment of renal function, urinalysis, and cardiac status, plus specialist follow-up and use of pregnancy-safe antihypertensives. Gestational hypertension by definition arises after 20 weeks. Abrupt cessation of treatment risks severe hypertension and stroke.

Question 24Antenatal Care and Normal Pregnancy

A woman at 28 weeks presents with itching of the palms and soles that is worse at night, without a rash. Which condition should be considered and investigated?

  1. Intrahepatic cholestasis of pregnancy, by measuring serum bile acids Correct answer.
  2. Simple eczema, treated with emollients only
  3. Normal pregnancy itching, requiring no investigation
  4. Scabies, treated with topical permethrin without investigation

Explanation

Pruritus of the palms and soles without a rash is the classic presentation of intrahepatic cholestasis of pregnancy, which is diagnosed by raised serum bile acids. The condition is associated with stillbirth and preterm birth and requires monitoring and treatment. Dismissing it as normal itching risks missing a serious disorder.

Question 25Antenatal Care and Normal Pregnancy

A woman at 34 weeks has a fundal height of 38 cm and a history of polyhydramnios on ultrasound. Which complication should be anticipated at delivery?

  1. Cord prolapse due to oligohydramnios
  2. Shoulder dystocia due to a small fetus
  3. Postpartum haemorrhage due to uterine overdistension Correct answer.
  4. Preterm labour due to a small-for-dates fetus

Explanation

Uterine overdistension from polyhydramnios impairs postpartum contraction and increases the risk of postpartum haemorrhage, so active management of the third stage and readiness for haemorrhage are essential. Polyhydramnios is also associated with malpresentation and cord prolapse when membranes rupture, but not with a small fetus or oligohydramnios.

Question 26Antenatal Care and Normal Pregnancy

A woman at 10 weeks' gestation attends her first antenatal visit. She has no symptoms and no history of illness. Which set of routine baseline investigations is most appropriate at this visit in the Cambodian antenatal package?

  1. Blood group and Rh, serum bile acids, and cervical swab for chlamydia
  2. Haemoglobin, oral glucose tolerance test, and midstream urine culture
  3. Haemoglobin, blood group and Rh, syphilis screening, and HIV testing Correct answer.
  4. Haemoglobin, serum creatinine, and 24-hour urine protein

Explanation

The first antenatal visit is the point at which baseline screening is done: haemoglobin to detect anaemia, ABO and Rh grouping to plan anti-D prophylaxis, and screening for syphilis and HIV so that treatment can start early enough to prevent vertical transmission. These tests are cheap, widely available and clearly change management, which is why they form the core package. Tests such as glucose tolerance testing or bile acids are targeted rather than universal at 10 weeks.

Question 27Antenatal Care and Normal Pregnancy

A woman at 12 weeks' gestation asks how many routine antenatal contacts she should expect if her pregnancy remains normal. Using the WHO 2016 antenatal care model adopted in Cambodia, how should the midwife respond?

  1. Four visits, one in each trimester and two in the last month
  2. Six contacts, starting at 20 weeks
  3. Twelve monthly visits until birth
  4. Eight contacts, with the first before 12 weeks Correct answer.

Explanation

The WHO 2016 model recommends eight antenatal contacts for a normal pregnancy, with the first contact occurring before 12 weeks' gestation. The schedule is front-loaded so that screening and preventive care happen early, and the number of contacts increases near term. This replaced the older four-visit focused antenatal care model.

Question 28Antenatal Care and Normal Pregnancy

A woman at 15 weeks' gestation reports nausea and vomiting that has persisted since early pregnancy. She is able to eat small meals, has lost no weight, and her urine ketones are negative. What is the most appropriate management?

  1. Refer her urgently for surgical assessment of a possible ectopic pregnancy
  2. Admit her for intravenous fluids and nothing by mouth until the vomiting stops
  3. Reassure her that this can persist into the second trimester and advise small frequent meals, avoiding fatty foods, with ginger or vitamin B6 for symptom relief Correct answer.
  4. Prescribe oral doxycycline while awaiting an ultrasound scan

Explanation

Nausea and vomiting in pregnancy is common and usually settles by 16 to 20 weeks; when the woman is eating, hydrated and ketone-free, it is managed with dietary advice and simple antiemetics such as vitamin B6 or ginger. Admission and intravenous fluids are reserved for hyperemesis with dehydration, weight loss or ketonuria. Ectopic pregnancy is not plausible at 15 weeks with an ongoing pregnancy.

Question 29Antenatal Care and Normal Pregnancy

A woman at 24 weeks' gestation is planning a long bus journey to visit her family in another province. She has no complications and her pregnancy is progressing normally. Which advice about travel is most appropriate?

  1. Travel should be avoided entirely until after birth because of the risk of preterm labour
  2. Travel is acceptable; she should move about or do ankle exercises hourly, drink plenty of water, and carry her antenatal card Correct answer.
  3. She should take aspirin before the journey to prevent thrombosis
  4. She may travel only if she first takes a prophylactic course of antibiotics

Explanation

For an uncomplicated pregnancy, long-distance travel is not prohibited; the main concern is venous stasis during prolonged sitting, which is reduced by regular movement, ankle exercises and adequate hydration. Carrying the antenatal card ensures that any facility she reaches has her history and test results. Antibiotics and aspirin are not indicated prophylactically for travel.

Question 30Antenatal Care and Normal Pregnancy

A woman at 28 weeks' gestation has a symphyseal-fundal height of 27 cm. Review of her record shows the measurement was 27 cm at 24 weeks. She feels fetal movements normally and has no bleeding or fluid loss. What is the most appropriate next step?

  1. Reassure her and repeat the fundal height measurement at the next routine contact in four weeks
  2. Advise bed rest at home and review her in two weeks
  3. Arrange an ultrasound scan to assess fetal growth and amniotic fluid volume Correct answer.
  4. Start a course of antenatal corticosteroids for fetal lung maturity

Explanation

Fundal height normally increases by roughly 1 cm per week in the third trimester, so an unchanged measurement over four weeks suggests static or impaired growth and warrants ultrasound assessment of fetal biometry and liquor volume. A single measurement can be misleading, but a flat trend is a recognised indication for further imaging. Corticosteroids are given for anticipated preterm birth, not for growth assessment.

Question 31Intrapartum Care and Normal Labour

During a vaginal examination in the active first stage of labour, which finding best describes full cervical dilatation?

  1. The cervix cannot be felt around the presenting part Correct answer.
  2. The cervix is 4 cm dilated and thick
  3. The presenting part is at the ischial spines
  4. The cervix is 8 cm dilated and thin

Explanation

Full dilatation is 10 cm, at which point the cervix is effaced and retracts so that no cervical rim can be palpated around the presenting part. A measurement of 8 cm or 4 cm indicates the first stage is still in progress. Station of the presenting part describes descent, not dilatation.

Question 32Intrapartum Care and Normal Labour

A woman at 39 weeks has regular painful contractions every 4 minutes, a cervix dilated 5 cm that is fully effaced, and spontaneous rupture of membranes with clear fluid. Which diagnosis is most appropriate?

  1. Threatened preterm labour
  2. Latent first stage of labour
  3. Second stage of labour
  4. Active first stage of labour Correct answer.

Explanation

Active first stage is defined by regular contractions with progressive cervical dilatation from about 5 cm in the presence of full effacement. The head is not yet born, so the second stage has not begun. Latent phase would apply below 5 cm with slower change, and the gestation is term, excluding preterm labour.

Question 33Intrapartum Care and Normal Labour

Which parameter is recorded on the partograph to monitor fetal wellbeing during labour?

  1. Bladder distension
  2. Cervical consistency
  3. Maternal temperature
  4. Fetal heart rate Correct answer.

Explanation

The partograph has a dedicated fetal condition section where the fetal heart rate is plotted every 30 minutes to detect bradycardia or tachycardia suggesting hypoxia. Maternal temperature and bladder distension are recorded in the maternal condition section. Cervical consistency is not a partograph parameter.

Question 34Intrapartum Care and Normal Labour

Which fetal heart rate pattern most strongly suggests umbilical cord compression during labour?

  1. Accelerations with fetal movement
  2. Early decelerations with gradual onset
  3. Variable decelerations with abrupt onset Correct answer.
  4. Baseline tachycardia of 165 beats per minute

Explanation

Variable decelerations are abrupt, V-shaped drops that vary in timing with contractions and reflect cord compression. Early decelerations are gradual and mirror contractions, reflecting head compression. Tachycardia may suggest maternal fever or hypoxia, and accelerations are reassuring.

Question 35Intrapartum Care and Normal Labour

A low-risk woman in active labour has a cervical dilatation plotted to the right of the alert line on the partograph. What is the most appropriate initial action?

  1. Rupture the membranes if still intact and await progress
  2. Immediately perform a caesarean section
  3. Reassess contractions, hydration, bladder and position, and consider referral Correct answer.
  4. Give oxytocin without further assessment

Explanation

Crossing the alert line signals slow progress and requires a structured review of the causes of poor progress, such as inadequate contractions, dehydration, full bladder or poor position, and consideration of transfer to a facility with surgical capacity. Surgery is reserved for confirmed obstruction or fetal compromise. Oxytocin should follow assessment, not precede it.

Question 36Intrapartum Care and Normal Labour

Which finding in the second stage indicates that the woman should be encouraged to push with contractions?

  1. Contractions every 10 minutes with a soft uterus
  2. Full dilatation with an urge to bear down Correct answer.
  3. Full dilatation with no descent of the head
  4. Cervix 8 cm dilated with a bulging membrane

Explanation

Once the cervix is fully dilated and the woman feels a spontaneous urge to bear down, active pushing is appropriate and shortens the second stage. Pushing before full dilatation risks cervical oedema and trauma. Ineffective contractions or no descent require reassessment rather than coaching to push.

Question 37Intrapartum Care and Normal Labour

During delivery of the head, which manoeuvre is used to control the speed of crowning and protect the perineum?

  1. Immediate episiotomy for every primigravida
  2. Applying gentle counter-pressure with the palm while the woman stops pushing Correct answer.
  3. Fundal pressure applied by an assistant
  4. Pulling firmly on the head to hasten delivery

Explanation

Controlled delivery of the head with counter-pressure and coaching the woman to breathe or stop pushing allows gradual stretching of the perineum and reduces tears. Pulling the head risks rapid expulsion and perineal injury. Routine episiotomy and fundal pressure are not recommended practices.

Question 38Intrapartum Care and Normal Labour

After the baby is born, which action best supports the third stage and reduces postpartum haemorrhage in a low-risk birth?

  1. Give a uterotonic and apply controlled cord traction with counter-traction Correct answer.
  2. Clamp the cord immediately and pull steadily without uterine support
  3. Wait for placental separation without any uterotonic
  4. Massage the fundus vigorously before the placenta is delivered

Explanation

Active management of the third stage combines a prophylactic uterotonic, controlled cord traction with counter-traction on the uterus, and assessment of uterine tone. This shortens the third stage and lowers the risk of haemorrhage. Vigorous massage before separation or traction without uterine support risks inversion or retained placenta.

Question 39Intrapartum Care and Normal Labour

A woman is fully dilated, the fetal head is visible and the perineum is stretching. Which sign confirms the second stage is progressing normally?

  1. The head advances with each contraction and recedes between them Correct answer.
  2. The woman has no urge to push and the head does not descend
  3. Fresh meconium appears with each contraction
  4. The fetal heart rate falls to 80 beats per minute persistently

Explanation

Descent of the head with each contraction and slight recession between them reflects normal progression through the second stage. A persistent heart rate of 80, absent descent or new meconium are warning signs requiring urgent assessment. Normal progress is shown by advancing descent and maternal effort.

Question 40Intrapartum Care and Normal Labour

Which mechanism of labour describes the fetal head turning so that the occiput moves toward the midline under the symphysis pubis?

  1. Engagement
  2. Restitution
  3. Extension
  4. Internal rotation Correct answer.

Explanation

Internal rotation occurs when the head rotates within the pelvis so the occiput aligns with the anteroposterior diameter, usually to occipito-anterior. Extension is the movement by which the head is born, and restitution is the small rotation after birth that realigns the head with the shoulders. Engagement is descent of the widest diameter into the pelvis.

Question 41Intrapartum Care and Normal Labour

A woman in the latent phase has irregular contractions, a cervix 2 cm dilated and is anxious. What is the most appropriate management?

  1. Perform caesarean section for failure to progress
  2. Admit for immediate amniotomy
  3. Provide reassurance, hydration, ambulation and review progress Correct answer.
  4. Start oxytocin infusion to augment labour

Explanation

The latent phase can last many hours and is managed with support, hydration, mobility and reassessment rather than intervention. Amniotomy and oxytocin are reserved for confirmed slow progress in the active phase. Caesarean section requires a clear indication such as obstruction or fetal compromise.

Question 42Intrapartum Care and Normal Labour

Which position during the first stage is most likely to promote fetal descent and maternal comfort in an uncomplicated labour?

  1. Standing still without any movement
  2. Upright or lateral positions with free movement Correct answer.
  3. Supine position with legs flat
  4. Lithotomy position for the whole first stage

Explanation

Upright and lateral positions use gravity to encourage descent, improve pelvic diameters and reduce aortocaval compression, while free movement improves comfort. Prolonged supine or lithotomy positions restrict mobility and may compress the vena cava. Immobility offers no advantage in normal labour.

Question 43Intrapartum Care and Normal Labour

Which feature distinguishes true labour from false labour?

  1. Contractions relieved by walking
  2. Absence of bloody show
  3. Progressive cervical dilatation and effacement Correct answer.
  4. Irregular contractions felt in the abdomen

Explanation

True labour produces regular, increasingly strong contractions with progressive cervical effacement and dilatation. False labour contractions are irregular, often relieved by activity, and do not change the cervix. Bloody show may or may not be present in either situation.

Question 44Intrapartum Care and Normal Labour

During the second stage, the fetal heart rate drops to 90 beats per minute and does not recover after a contraction. What is the priority action?

  1. Reposition the mother, stop oxytocin if running, and prepare for expedited delivery Correct answer.
  2. Continue pushing and recheck in 30 minutes
  3. Rupture membranes if still intact
  4. Give a sedative to reduce maternal anxiety

Explanation

Persistent fetal bradycardia in the second stage is an obstetric emergency requiring intrauterine resuscitation, including position change, stopping oxytocin and preparing for expedited vaginal or operative delivery. Delaying reassessment risks fetal hypoxia. Sedation and amniotomy do not address the compromised fetus.

Question 45Intrapartum Care and Normal Labour

Which finding during a vaginal examination suggests occipito-posterior position?

  1. The anterior fontanelle is felt directly under the symphysis
  2. The sagittal suture lies obliquely with the posterior fontanelle felt toward the sacrum Correct answer.
  3. The cervix is fully effaced and 3 cm dilated
  4. The ischial spines are felt on both sides of the pelvis

Explanation

In occipito-posterior position the posterior fontanelle is directed toward the sacrum and the sagittal suture lies obliquely, often with a deflexed head. Palpating the anterior fontanelle anteriorly would suggest a different orientation. Cervical dilatation and ischial spines describe other parameters, not position.

Question 46Intrapartum Care and Normal Labour

Which is the recommended routine for monitoring the fetal heart rate in the active first stage of an uncomplicated labour?

  1. Auscultate once on admission only
  2. Auscultate every 4 hours
  3. Auscultate continuously by hand without rest
  4. Auscultate every 30 minutes for one minute after a contraction Correct answer.

Explanation

In low-risk labour, intermittent auscultation every 30 minutes in the first stage and every 15 minutes in the second stage, listening for a full minute after a contraction, is standard. Less frequent listening may miss developing hypoxia. Continuous manual auscultation is impractical and continuous electronic monitoring is reserved for higher-risk cases.

Question 47Intrapartum Care and Normal Labour

A woman arrives in labour with a history of previous caesarean section and now has strong contractions and a scar that is tender on palpation. What is the most likely concern?

  1. Physiological retraction ring
  2. Full bladder distension
  3. Normal scar stretching
  4. Impending uterine rupture Correct answer.

Explanation

A tender scar with strong contractions and a history of previous caesarean section raises concern for uterine rupture, which is an emergency requiring immediate laparotomy. Normal scar stretching does not cause marked tenderness. A retraction ring is a sign of obstructed labour, and bladder distension does not cause scar tenderness.

Question 48Intrapartum Care and Normal Labour

Which practice is recommended to reduce perineal trauma during spontaneous vaginal birth?

  1. Warm compresses and perineal support during crowning Correct answer.
  2. Routine mediolateral episiotomy
  3. Manual stretching of the perineum with force
  4. Directed pushing from the start of the second stage with a closed glottis

Explanation

Warm compresses and hands-on perineal support during crowning reduce the incidence and severity of perineal tears. Routine episiotomy increases trauma without benefit. Forced stretching and prolonged breath-holding with directed pushing are not recommended and may cause injury.

Question 49Intrapartum Care and Normal Labour

Which statement correctly describes the normal duration of the second stage in a nulliparous woman without epidural analgesia?

  1. It should always be completed within 15 minutes
  2. It is normally longer than the first stage
  3. It has no defined upper limit regardless of progress
  4. Up to about 3 hours may be normal if progress is occurring Correct answer.

Explanation

Guidelines allow up to about 3 hours in nulliparous women without epidural and up to 2 hours with epidural, provided there is continuing descent and no fetal compromise. A 15-minute limit is unrealistic, and an unlimited second stage without progress assessment is unsafe. The first stage is normally much longer.

Question 50Intrapartum Care and Normal Labour

A woman at 38 weeks presents with spontaneous rupture of membranes and no contractions. What is the most appropriate initial assessment?

  1. Give antibiotics and discharge home without review
  2. Perform immediate caesarean section
  3. Await labour for 7 days at home
  4. Confirm fetal wellbeing, assess for infection and plan induction if labour does not start Correct answer.

Explanation

Pre-labour rupture at term requires confirmation of fetal wellbeing, assessment for signs of infection and a plan for induction, usually within 24 hours, if labour does not begin spontaneously. Immediate caesarean is not indicated without other complications. Discharge without review or prolonged waiting increases infection risk.