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NNC NLEM Midwifery study materials
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NNC NLEM Midwifery practice questions

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Question 1Antenatal Care and Midwifery Assessment

A pregnant woman at 28 weeks' gestation has a haemoglobin of 9.8 g/dL. According to WHO thresholds, how should this be classified?

  1. Severe anaemia
  2. Normal for pregnancy
  3. Mild anaemia Correct answer.
  4. Moderate anaemia

Explanation

WHO defines anaemia in pregnancy as haemoglobin below 11.0 g/dL. Mild anaemia is 10.0–10.9 g/dL, moderate is 7.0–9.9 g/dL, and severe is below 7.0 g/dL. A value of 9.8 g/dL therefore falls into the moderate category, not mild.

Question 2Antenatal Care and Midwifery Assessment

During a routine antenatal visit, a midwife plots the fundal height on a chart. At 24 weeks' gestation, the fundal height is 20 cm. What is the most appropriate next action?

  1. Schedule the next visit in 8 weeks
  2. Reassure the woman that this is normal
  3. Advise the woman to increase her dietary intake
  4. Arrange an ultrasound scan for fetal growth assessment Correct answer.

Explanation

Fundal height should approximately equal gestational age in weeks between 20 and 36 weeks. A fundal height 4 cm below the expected value suggests fetal growth restriction or oligohydramnios and warrants ultrasound assessment. Reassurance or dietary advice alone would delay diagnosis.

Question 3Antenatal Care and Midwifery Assessment

Which vaccine is routinely recommended during pregnancy to prevent neonatal tetanus?

  1. Human papillomavirus (HPV) vaccine
  2. Measles-mumps-rubella (MMR)
  3. Varicella vaccine
  4. Tetanus-diphtheria toxoid (Td) Correct answer.

Explanation

Tetanus-diphtheria toxoid is safe in pregnancy and prevents maternal and neonatal tetanus. MMR and varicella are live vaccines and are contraindicated during pregnancy. HPV vaccine is not routinely recommended in pregnancy.

Question 4Antenatal Care and Midwifery Assessment

A woman at 34 weeks' gestation presents with a blood pressure of 150/100 mmHg and 2+ proteinuria on dipstick. She has no symptoms. What is the most likely diagnosis?

  1. Gestational hypertension
  2. Pre-eclampsia Correct answer.
  3. Eclampsia
  4. Chronic hypertension

Explanation

Pre-eclampsia is defined as new hypertension after 20 weeks' gestation accompanied by proteinuria or other end-organ dysfunction. This woman has both hypertension and proteinuria. Gestational hypertension lacks proteinuria, chronic hypertension predates pregnancy or is present before 20 weeks, and eclampsia involves seizures.

Question 5Antenatal Care and Midwifery Assessment

A midwife is assessing a woman at 38 weeks' gestation who reports reduced fetal movements for the past 24 hours. What is the priority action?

  1. Perform an ultrasound scan and cardiotocography (CTG) Correct answer.
  2. Reassure the woman that reduced movements are normal at term
  3. Arrange a routine antenatal visit in one week
  4. Advise the woman to rest and monitor movements for another 24 hours

Explanation

Reduced fetal movements can be a sign of fetal compromise and require prompt assessment with ultrasound and CTG to confirm fetal wellbeing. Delaying assessment increases the risk of stillbirth. Reassurance without investigation is unsafe.

Question 6Antenatal Care and Midwifery Assessment

Which of the following is the most accurate method for estimating gestational age in the first trimester?

  1. Crown-rump length (CRL) measurement Correct answer.
  2. Fundal height
  3. Fetal heart auscultation
  4. Last menstrual period (LMP)

Explanation

Crown-rump length measurement by ultrasound between 7 and 13 weeks is the most accurate method for dating a pregnancy, with an accuracy of ±5–7 days. LMP can be unreliable due to irregular cycles or recall error, and fundal height and fetal heart auscultation are less precise.

Question 7Antenatal Care and Midwifery Assessment

A pregnant woman at 26 weeks' gestation has a random blood glucose of 11.1 mmol/L. What is the most appropriate next step?

  1. Repeat random glucose in 4 weeks
  2. Reassure and continue routine care
  3. Perform an oral glucose tolerance test (OGTT) Correct answer.
  4. Start insulin therapy immediately

Explanation

A random glucose ≥11.1 mmol/L is suggestive of hyperglycaemia and requires confirmation with an OGTT to diagnose gestational diabetes. Immediate insulin without confirmation is inappropriate, and repeating random glucose or reassurance would delay diagnosis.

Question 8Antenatal Care and Midwifery Assessment

Which of the following is a risk factor for gestational diabetes mellitus (GDM)?

  1. Multiparity without previous GDM
  2. Previous macrosomic infant Correct answer.
  3. Pre-pregnancy BMI of 22 kg/m²
  4. Maternal age under 25 years

Explanation

A history of a macrosomic infant (birthweight >4.5 kg) is a recognised risk factor for GDM. Young maternal age, normal BMI, and multiparity without prior GDM are not established risk factors.

Question 9Antenatal Care and Midwifery Assessment

A woman at 10 weeks' gestation has a haemoglobin of 10.5 g/dL and ferritin of 12 µg/L. What is the most appropriate management?

  1. Intravenous iron
  2. Oral iron supplementation Correct answer.
  3. No treatment needed
  4. Blood transfusion

Explanation

A ferritin below 30 µg/L indicates iron deficiency, and haemoglobin of 10.5 g/dL indicates mild anaemia. Oral iron is the first-line treatment. Blood transfusion is reserved for severe symptomatic anaemia, and intravenous iron is considered when oral iron is not tolerated or ineffective.

Question 10Antenatal Care and Midwifery Assessment

Which of the following is a component of the routine antenatal assessment at the first visit?

  1. Blood pressure measurement Correct answer.
  2. Amniocentesis
  3. Contraction stress test
  4. Cervical dilatation check

Explanation

Blood pressure measurement is a standard component of the first antenatal visit to establish a baseline and screen for hypertension. Cervical dilatation, contraction stress test, and amniocentesis are not routine at the first visit.

Question 11Antenatal Care and Midwifery Assessment

A woman at 36 weeks' gestation has a singleton breech presentation confirmed by ultrasound. What is the most appropriate management option to discuss?

  1. Await spontaneous version
  2. External cephalic version (ECV) Correct answer.
  3. Immediate caesarean section
  4. Induction of labour

Explanation

External cephalic version is offered for breech presentation at term to increase the chance of vaginal delivery. Immediate caesarean without labour is not routinely indicated, induction of labour is not recommended for breech, and spontaneous version is unlikely at 36 weeks.

Question 12Antenatal Care and Midwifery Assessment

Which of the following is a warning sign that requires immediate referral during pregnancy?

  1. Visual disturbances Correct answer.
  2. Occasional backache
  3. Increased appetite
  4. Mild ankle oedema

Explanation

Visual disturbances such as blurred vision or flashing lights can indicate pre-eclampsia and require immediate assessment. Mild ankle oedema, occasional backache, and increased appetite are common and usually benign in pregnancy.

Question 13Antenatal Care and Midwifery Assessment

A woman at 32 weeks' gestation has a blood pressure of 140/90 mmHg on two occasions 4 hours apart, with no proteinuria. She is asymptomatic. What is the most likely diagnosis?

  1. Gestational hypertension Correct answer.
  2. Pre-eclampsia
  3. White-coat hypertension
  4. Chronic hypertension

Explanation

Gestational hypertension is defined as new hypertension after 20 weeks' gestation without proteinuria or other features of pre-eclampsia. Pre-eclampsia requires proteinuria or end-organ dysfunction, chronic hypertension is present before 20 weeks, and white-coat hypertension is elevated blood pressure only in clinical settings.

Question 14Antenatal Care and Midwifery Assessment

Which of the following is the recommended daily folic acid dose for a woman with a previous child with a neural tube defect?

  1. 4 mg
  2. 0.4 mg
  3. 1 mg
  4. 5 mg Correct answer.

Explanation

For women with a previous affected pregnancy, a higher dose of 5 mg daily is recommended, starting at least one month before conception and continuing through the first trimester. The standard dose for low-risk women is 0.4 mg, and 1 mg is used for other high-risk conditions such as diabetes or obesity.

Question 15Antenatal Care and Midwifery Assessment

A midwife is performing an abdominal examination on a woman in the third trimester. Which manoeuvre is used to determine the fetal lie?

  1. Third Leopold manoeuvre
  2. Second Leopold manoeuvre
  3. First Leopold manoeuvre Correct answer.
  4. Fourth Leopold manoeuvre

Explanation

The first Leopold manoeuvre palpates the upper abdomen to identify the fetal part occupying the fundus, helping to determine lie and presentation. The second manoeuvre determines position, the third assesses engagement, and the fourth determines attitude and descent.

Question 16Antenatal Care and Midwifery Assessment

A woman at 28 weeks' gestation has a symphysio-fundal height of 32 cm. What is the most appropriate interpretation?

  1. Suspected oligohydramnios
  2. Normal for gestational age Correct answer.
  3. Suspected intrauterine growth restriction
  4. Suspected macrosomia

Explanation

Between 20 and 36 weeks, fundal height in centimetres roughly equals gestational age in weeks, with a normal range of ±2 cm. A value of 32 cm at 28 weeks is within this range and is considered normal. Values outside this range would prompt further assessment.

Question 17Antenatal Care and Midwifery Assessment

Which of the following is a contraindication to external cephalic version (ECV)?

  1. Oligohydramnios Correct answer.
  2. Gestational age of 37 weeks
  3. Multiparity
  4. Anterior placenta

Explanation

Oligohydramnios is a contraindication to ECV because reduced amniotic fluid volume makes version difficult and increases the risk of fetal compromise. Multiparity, anterior placenta, and gestational age of 37 weeks are not contraindications.

Question 18Antenatal Care and Midwifery Assessment

A woman at 30 weeks' gestation has a haemoglobin of 8.5 g/dL and reports fatigue. She is otherwise well. What is the most appropriate initial management?

  1. Intravenous iron
  2. Immediate blood transfusion
  3. No treatment, recheck at 36 weeks
  4. Oral iron and recheck in 2 weeks Correct answer.

Explanation

Moderate anaemia (7.0–9.9 g/dL) with symptoms is initially managed with oral iron, and haemoglobin should be rechecked in 2–4 weeks. Blood transfusion is reserved for severe anaemia or severe symptoms, and intravenous iron is considered if oral iron is ineffective or not tolerated.

Question 19Antenatal Care and Midwifery Assessment

Which of the following is the most common cause of post-partum haemorrhage?

  1. Coagulopathy
  2. Genital tract trauma
  3. Uterine atony Correct answer.
  4. Retained placenta

Explanation

Uterine atony is the most common cause of postpartum haemorrhage, accounting for about 70% of cases. Genital tract trauma, retained placenta, and coagulopathy are less common causes.

Question 20Antenatal Care and Midwifery Assessment

A woman at 34 weeks' gestation has a fundal height of 38 cm. Which of the following is the most appropriate next step?

  1. Schedule induction of labour
  2. Perform a glucose tolerance test
  3. Reassure and continue routine care
  4. Arrange an ultrasound scan for growth and amniotic fluid assessment Correct answer.

Explanation

A fundal height 4 cm greater than gestational age may indicate macrosomia, polyhydramnios, or multiple pregnancy, and should be evaluated by ultrasound. Reassurance, induction, or isolated glucose testing would not adequately assess the cause.

Question 21Antenatal Care and Midwifery Assessment

Which of the following is a characteristic of a normal fetal heart rate pattern on cardiotocography (CTG)?

  1. Absence of variability
  2. Presence of accelerations Correct answer.
  3. Baseline of 160–180 bpm
  4. Late decelerations

Explanation

A normal CTG shows a baseline rate of 110–160 bpm, moderate variability, accelerations, and no decelerations. Accelerations are a sign of fetal wellbeing. Baseline of 160–180 bpm, late decelerations, and absent variability are abnormal features.

Question 22Antenatal Care and Midwifery Assessment

A woman at 12 weeks' gestation has a body mass index (BMI) of 35 kg/m². Which of the following is the recommended total gestational weight gain?

  1. 5–9 kg Correct answer.
  2. No weight gain recommended
  3. 11.5–16 kg
  4. 7–11.5 kg

Explanation

For women with a pre-pregnancy BMI of 30 kg/m² or more, the Institute of Medicine recommends a total gestational weight gain of 5–9 kg. The ranges 11.5–16 kg and 7–11.5 kg apply to normal-weight and overweight women respectively, and no weight gain is not recommended.

Question 23Antenatal Care and Midwifery Assessment

A woman at 26 weeks' gestation has a blood pressure of 150/95 mmHg and 1+ proteinuria. She has a history of chronic hypertension. What is the most likely diagnosis?

  1. Chronic hypertension with superimposed pre-eclampsia Correct answer.
  2. Eclampsia
  3. Gestational hypertension
  4. Pre-eclampsia

Explanation

In a woman with chronic hypertension, new proteinuria after 20 weeks suggests superimposed pre-eclampsia. Gestational hypertension lacks proteinuria, pre-eclampsia occurs in women without prior hypertension, and eclampsia involves seizures.

Question 24Antenatal Care and Midwifery Assessment

Which of the following is the most appropriate screening test for gestational diabetes mellitus at 24–28 weeks' gestation?

  1. Fasting plasma glucose
  2. 75-g oral glucose tolerance test (OGTT) Correct answer.
  3. Random blood glucose
  4. Urine glucose dipstick

Explanation

The 75-g OGTT is the standard diagnostic test for GDM at 24–28 weeks. Fasting plasma glucose alone is less sensitive, random glucose is not diagnostic, and urine glucose dipstick is not recommended for screening.

Question 25Antenatal Care and Midwifery Assessment

A midwife is reviewing the antenatal record of a woman at 38 weeks' gestation. Which of the following findings should prompt immediate referral?

  1. Mild pedal oedema
  2. Fetal heart rate of 120 bpm
  3. Severe headache and visual changes Correct answer.
  4. Blood pressure of 130/80 mmHg

Explanation

Severe headache and visual changes are warning signs of pre-eclampsia and require immediate assessment. A blood pressure of 130/80 mmHg, fetal heart rate of 120 bpm, and mild pedal oedema are within normal limits.

Question 26Antenatal Care and Midwifery Assessment

A woman at 18 weeks' gestation attends her first antenatal visit. She reports no fetal movement yet and asks when she should expect to feel it. In a nulliparous woman, quickening is most typically first perceived at approximately which gestational age?

  1. 14 to 16 weeks
  2. 24 to 26 weeks
  3. 12 to 14 weeks
  4. 18 to 20 weeks Correct answer.

Explanation

Quickening in a first pregnancy is usually first appreciated between about 18 and 20 weeks, reflecting the gestational age at which fetal movements become strong enough to be felt through the abdominal wall. Multiparous women often perceive movement earlier, around 16 to 18 weeks, because they recognise the sensation. Absence of movement before this time is not itself abnormal.

Question 27Antenatal Care and Midwifery Assessment

A midwife is palpating the abdomen of a woman at 34 weeks' gestation. To assess the fetal lie and presenting part by feeling the shape and consistency of the contents of the lower uterus, which abdominal palpation manoeuvre should be performed first in the sequence?

  1. Pelvic palpation using the first manoeuvre to determine the presenting part
  2. Fundal palpation to identify the fetal poles Correct answer.
  3. Lateral palpation to identify the fetal back
  4. Pawlik's grip to confirm the presenting part

Explanation

Abdominal examination proceeds in a set order, beginning with fundal palpation to identify which fetal pole occupies the fundus. This establishes the lie before lateral and pelvic palpation refine the position and presenting part. Pawlik's grip is used at the lower pole to assess the presenting part, not first.

Question 28Antenatal Care and Midwifery Assessment

A woman at 24 weeks' gestation has a midstream urine culture taken at booking that grows a single organism at a concentration of 10⁵ colony-forming units per mL. She has no urinary symptoms. What is the most appropriate management?

  1. Reassure her that asymptomatic growth requires no treatment
  2. Treat with an appropriate antibiotic guided by sensitivities and arrange a follow-up culture Correct answer.
  3. Repeat the culture after two weeks and treat only if symptoms develop
  4. Refer for immediate intravenous antibiotics and admission

Explanation

Significant asymptomatic bacteriuria in pregnancy, generally defined as a single organism at 10⁵ CFU/mL or more, warrants antibiotic treatment guided by sensitivities because untreated infection predisposes to pyelonephritis and preterm birth. A follow-up culture confirms clearance after treatment. Symptom-based management alone is inadequate in pregnancy.

Question 29Antenatal Care and Midwifery Assessment

A woman at 32 weeks' gestation reports a persistent itchy rash on her abdomen and limbs, worse at night, with no other symptoms. On examination there are excoriations but no vesicles. Which condition should the midwife consider first, and what is the appropriate initial action?

  1. Obstetric cholestasis; arrange immediate liver function tests
  2. Pemphigoid gestationis; refer urgently for skin biopsy
  3. Intrahepatic cholestasis of pregnancy; arrange serum bile acids and liver function tests Correct answer.
  4. Polymorphic eruption of pregnancy; recommend emollients and review

Explanation

Generalised itching that is worse at night, particularly without a primary rash, raises suspicion of intrahepatic cholestasis of pregnancy, which requires serum bile acid measurement and liver function tests. Itching in cholestasis is often most intense on the palms and soles and may occur without visible skin changes. Confirming bile acid levels guides monitoring and timing of birth.

Question 30Antenatal Care and Midwifery Assessment

A woman at 38 weeks' gestation with a singleton pregnancy has a cardiotocograph showing a baseline of 140 beats per minute, moderate variability, and no decelerations over 20 minutes. She reports good fetal movements. According to a standard categorisation, how should this trace be classified and what action follows?

  1. Category III (abnormal); prepare for immediate caesarean section
  2. Category II (indeterminate); start maternal oxygen and intravenous fluids
  3. Category II (indeterminate); perform a fetal scalp stimulation test
  4. Category I (normal); no intervention required, continue routine antenatal care Correct answer.

Explanation

A trace with a baseline of 110 to 160 beats per minute, moderate variability, and no late or variable decelerations meets the criteria for a normal (category I) trace. No intervention is needed and routine care continues. Category II traces have features that are neither normal nor clearly abnormal and require further evaluation.

Question 31Normal Labour and Birth

During a low-risk labour, at what cervical dilatation does the second stage of labour traditionally begin?

  1. Rupture of the membranes
  2. Descent of the fetal head to the pelvic floor
  3. Full dilatation of the cervix (10 cm) Correct answer.
  4. Onset of regular painful contractions

Explanation

The second stage of labour is defined as the period from full cervical dilatation (about 10 cm) until the baby is born. Membrane rupture and the onset of regular contractions belong to earlier phases, and head descent is a process occurring within the second stage rather than its defining start.

Question 32Normal Labour and Birth

Which physiological change is most characteristic of the latent first stage of labour?

  1. Progressive cervical effacement and slow dilatation Correct answer.
  2. Complete perineal stretching
  3. Urge to push with each contraction
  4. Rapid descent of the presenting part

Explanation

The latent phase is characterised by gradual cervical effacement and slow dilatation up to about 4-5 cm, with irregular contractions. Rapid descent, an urge to push, and perineal stretching are features of advanced first or second stage.

Question 33Normal Labour and Birth

A midwife notes the fetal head is at station 0. What does this indicate about the presenting part?

  1. It is 2 cm below the ischial spines
  2. It is 3 cm above the pelvic brim
  3. It is visible at the vulva
  4. It is at the level of the ischial spines Correct answer.

Explanation

Station 0 means the leading edge of the presenting part is level with the ischial spines, the reference point for pelvic station. Negative stations indicate the head is above the spines and positive stations indicate it is below.

Question 34Normal Labour and Birth

Which finding best describes a normal fetal heart rate pattern in established labour?

  1. Baseline 160-170 bpm with late decelerations
  2. Baseline 170 bpm with absent variability
  3. Baseline 100 bpm with minimal variability
  4. Baseline 110-160 bpm with normal variability Correct answer.

Explanation

A normal intrapartum cardiotocograph has a baseline between 110 and 160 bpm, moderate variability, and no pathological decelerations. Rates above 160 or below 110, reduced variability, and late decelerations suggest fetal compromise.

Question 35Normal Labour and Birth

Which mechanism of labour describes the fetal head entering the pelvic inlet with its sagittal suture aligned to the transverse diameter?

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

Explanation

Engagement occurs when the widest transverse diameter of the head passes the pelvic inlet, commonly with the sagittal suture in the transverse diameter and the head synclitic. Extension, internal rotation, and restitution are later cardinal movements.

Question 36Normal Labour and Birth

What is the primary physiological purpose of uterine retraction during labour?

  1. To maintain the shortened length of uterine muscle fibres after contractions Correct answer.
  2. To increase maternal blood pressure
  3. To reduce placental blood flow permanently
  4. To prevent cervical dilatation

Explanation

Retraction is the property by which uterine muscle fibres shorten during a contraction and retain part of that shortening afterwards, contributing to progress and haemostasis after delivery. It does not permanently reduce placental perfusion or prevent dilatation.

Question 37Normal Labour and Birth

Which position is generally recommended for a woman in the second stage without epidural analgesia to optimise pelvic dimensions?

  1. Lithotomy with legs in stirrups
  2. Trendelenburg position
  3. Supine with a wedge under the right hip
  4. Upright or lateral positions Correct answer.

Explanation

Upright and lateral positions enlarge pelvic outlet dimensions, use gravity, and are associated with fewer instrumental births. Lithotomy and supine positions restrict pelvic movement and may compress the vena cava.

Question 38Normal Labour and Birth

Which hormone is primarily responsible for uterine contractions during established labour?

  1. Prolactin
  2. Human chorionic gonadotropin
  3. Progesterone
  4. Oxytocin Correct answer.

Explanation

Oxytocin drives coordinated myometrial contractions, and its receptors increase near term. Progesterone maintains quiescence during pregnancy, while prolactin supports lactation and hCG maintains the corpus luteum.

Question 39Normal Labour and Birth

A nulliparous woman in active labour has contractions every 4 minutes lasting 30 seconds. How should the midwife interpret this?

  1. Inadequate frequency and duration requiring assessment Correct answer.
  2. Normal only in the second stage
  3. Sign of precipitate labour
  4. Adequate contraction pattern for active labour

Explanation

Active first-stage contractions are typically 3-5 in 10 minutes, each lasting 45-60 seconds. Contractions every 4 minutes lasting only 30 seconds are shorter than expected, so the midwife should assess progress and consider whether augmentation is needed.

Question 40Normal Labour and Birth

During a vaginal examination the midwife finds the cervix 6 cm dilated, soft, and the head at station -1. Which phase of labour is this?

  1. Latent first stage
  2. Active first stage Correct answer.
  3. Second stage
  4. Third stage

Explanation

Active first stage is defined by progressive dilatation from about 5-6 cm with regular contractions. Latent phase ends around 4-5 cm, and second and third stages occur after full dilatation and birth respectively.

Question 41Normal Labour and Birth

A woman at 8 cm dilatation reports a sudden gush of clear fluid. What is the most appropriate immediate midwifery action?

  1. Delay any assessment for two hours
  2. Advise the woman to ambulate briskly
  3. Administer an enema
  4. Perform a sterile vaginal examination to assess cord prolapse risk and fetal status Correct answer.

Explanation

Spontaneous rupture of membranes in labour warrants prompt assessment of the fetal heart rate and, where indicated, a sterile examination to exclude cord prolapse and check progress. Ambulation, enemas, or delay could miss a cord prolapse.

Question 42Normal Labour and Birth

Which observation suggests the onset of the expulsive phase in a woman without epidural analgesia?

  1. Contractions becoming irregular and painless
  2. An involuntary urge to bear down with contractions Correct answer.
  3. Cervical dilatation of 4 cm
  4. A sudden drop in maternal temperature

Explanation

An involuntary urge to push, often with perineal pressure, signals that the presenting part is descending to the pelvic floor near full dilatation. Irregular painless contractions and 4 cm dilatation describe earlier labour.

Question 43Normal Labour and Birth

The fetal heart rate shows variable decelerations during contractions. What is the most likely cause?

  1. Maternal pyrexia
  2. Uteroplacental insufficiency
  3. Umbilical cord compression Correct answer.
  4. Fetal head compression

Explanation

Variable decelerations are abrupt drops in fetal heart rate that vary in timing and shape, typically reflecting umbilical cord compression. Uteroplacental insufficiency causes late decelerations, and head compression causes early decelerations.

Question 44Normal Labour and Birth

A woman in the second stage has been pushing for 45 minutes and the perineum is beginning to bulge with the head visible. What is the most appropriate action?

  1. Support the perineum and encourage controlled gentle pushing Correct answer.
  2. Perform an episiotomy immediately
  3. Ask the woman to hold her breath for 20 seconds per contraction
  4. Encourage rapid forceful pushing to expedite birth

Explanation

Once the head is crowning, controlled pushing with perineal support reduces the risk of perineal trauma. Rapid forceful pushing or prolonged breath-holding increases tearing and fetal hypoxia risk, and episiotomy is not routine.

Question 45Normal Labour and Birth

Which cardinal movement allows the fetal shoulders to negotiate the pelvic outlet after the head is born?

  1. Descent
  2. Extension
  3. External rotation and lateral flexion Correct answer.
  4. Flexion

Explanation

After the head is born, external rotation aligns the shoulders with the anteroposterior diameter, and lateral flexion allows the anterior shoulder to deliver under the symphysis pubis. Flexion and extension apply mainly to the head.

Question 46Normal Labour and Birth

A woman's cervix is fully dilated but she has no urge to push and the fetal head is at station -2. What is the most appropriate management?

  1. Immediate instrumental delivery
  2. Oxygen by mask continuously
  3. Allow a period of rest and passive descent with monitoring Correct answer.
  4. Immediate directed pushing with each contraction

Explanation

When the head is high and there is no urge to push, a period of passive descent with continued fetal monitoring is appropriate before active pushing. Directed pushing at a high station increases fatigue and fetal compromise risk, and instrumental delivery needs an indication.

Question 47Normal Labour and Birth

During the third stage, which sign most reliably indicates that placental separation has occurred?

  1. Continued strong contractions without bleeding
  2. A fall in maternal pulse
  3. Maternal request to push
  4. A gush of blood and lengthening of the umbilical cord Correct answer.

Explanation

Placental separation is signalled by a gush of blood, lengthening of the cord, and the uterus becoming firm and globular. Continued contractions without bleeding or maternal request do not confirm separation.

Question 48Normal Labour and Birth

Which action best supports a physiological third stage in a low-risk woman who declines uterotonics?

  1. Manual removal of the placenta within 5 minutes
  2. Skin-to-skin contact and early breastfeeding with expectant management Correct answer.
  3. Immediate cord clamping and controlled cord traction
  4. Fundal pressure to expel the placenta

Explanation

Physiological management relies on skin-to-skin contact, early breastfeeding, and gravity-assisted delivery of the placenta without routine uterotonics. Immediate clamping, fundal pressure, and manual removal are not part of expectant management.

Question 49Normal Labour and Birth

A woman at 38 weeks presents with regular contractions every 3 minutes, cervix 4 cm dilated and 90% effaced. How should the midwife classify this?

  1. False labour
  2. Precipitate labour
  3. Active labour Correct answer.
  4. Threatened preterm labour

Explanation

Regular contractions with a cervix 4 cm dilated and well effaced at term indicate active labour. False labour lacks progressive cervical change, precipitate labour is very rapid, and threatened preterm labour would occur before 37 weeks.

Question 50Normal Labour and Birth

Why is the supine position discouraged during the second stage of labour?

  1. It reduces uterine retraction
  2. It causes fetal head extension
  3. It increases aortocaval compression and reduces pelvic outlet dimensions Correct answer.
  4. It prevents cervical dilatation

Explanation

Lying supine allows the gravid uterus to compress the aorta and vena cava, reducing cardiac output and placental perfusion, and it also restricts pelvic outlet dimensions. It does not directly cause head extension or block dilatation.