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NZ Midwifery Registration study materials
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NZ Midwifery Registration practice questions

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Question 1Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

During a normal menstrual cycle, which hormonal change is primarily responsible for triggering ovulation?

  1. A surge in luteinising hormone (LH) secretion Correct answer.
  2. A decrease in oestradiol production by the dominant follicle
  3. A fall in follicle-stimulating hormone (FSH) secretion
  4. A gradual rise in progesterone from the corpus luteum

Explanation

Ovulation is triggered by a sharp mid-cycle surge in luteinising hormone (LH) that follows peak oestradiol production by the mature dominant follicle. This LH surge causes the follicle to rupture and release the oocyte, typically about 24–36 hours later. Progesterone rises only after ovulation, when the corpus luteum forms.

Question 2Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which structure is the primary site of fertilisation in a normal pregnancy?

  1. The ampulla of the fallopian tube Correct answer.
  2. The fundus of the uterus
  3. The cervix
  4. The ovary

Explanation

Fertilisation normally occurs in the ampulla, the widest and most lateral part of the fallopian tube, where sperm meets the oocyte after ovulation. The resulting zygote then travels to the uterus for implantation. Implantation in the uterine fundus occurs several days later, not at fertilisation.

Question 3Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 10 weeks' gestation reports urinary frequency. Which physiological explanation best accounts for this early-pregnancy symptom?

  1. Reduced plasma volume causing concentrated urine
  2. Decreased progesterone leading to bladder irritability
  3. Increased glomerular filtration rate and pressure from the enlarging uterus on the bladder Correct answer.
  4. A fall in cardiac output reducing renal perfusion

Explanation

In early pregnancy, renal blood flow and glomerular filtration rate increase by up to 50%, producing more urine. At the same time, the growing uterus presses on the bladder, reducing its capacity. Together these cause urinary frequency, which often settles in the second trimester as the uterus rises out of the pelvis.

Question 4Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which fetal circulation shunt allows most oxygenated blood to bypass the developing liver and pass directly into the inferior vena cava?

  1. The foramen ovale
  2. The umbilical vein
  3. The ductus arteriosus
  4. The ductus venosus Correct answer.

Explanation

The ductus venosus connects the umbilical vein to the inferior vena cava, shunting well-oxygenated blood past the hepatic sinusoids. The foramen ovale and ductus arteriosus are cardiac shunts that direct blood away from the pulmonary circulation. The umbilical vein carries oxygenated blood to the fetus but is not itself a shunt.

Question 5Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

During the second stage of labour, which mechanism of fetal descent occurs first?

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

Explanation

The cardinal movements of labour begin with engagement, when the widest transverse diameter of the fetal head passes through the pelvic inlet. Flexion, internal rotation, extension and restitution follow in sequence. Engagement is therefore the first mechanical event of descent.

Question 6Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman in the active phase of the first stage of labour has a cervical dilatation of 6 cm. Which finding best indicates adequate progress according to the partogram?

  1. Cervical dilatation advancing at least 1 cm per hour Correct answer.
  2. Contractions occurring every 5 minutes lasting 20 seconds
  3. Cervical dilatation unchanged over 4 hours with strong contractions
  4. Station of the fetal head remaining at −2 over 3 hours

Explanation

In the active phase, progress is assessed by cervical dilatation, which should advance at least 1 cm per hour in a first labour. A slower rate may indicate poor progress and warrants further assessment. Contraction frequency, duration and fetal station are also monitored but are not the primary measure of active-phase progress.

Question 7Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which physiological change in the postnatal period promotes involution of the uterus?

  1. Sustained oxytocin release during breastfeeding Correct answer.
  2. Reduced prolactin secretion
  3. Increased oestrogen production by the ovaries
  4. A rise in progesterone from the corpus luteum

Explanation

Oxytocin released during breastfeeding stimulates uterine contractions, which help the uterus involute and reduce the risk of postpartum haemorrhage. After birth, progesterone and oestrogen levels fall sharply, removing their relaxing influence on the myometrium. Prolactin rises to support lactation but does not drive involution.

Question 8Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 34 weeks' gestation has a blood pressure of 150/100 mmHg and 2+ proteinuria. Which pathophysiological process best explains these findings in pre-eclampsia?

  1. Reduced cardiac output leading to renal hypoperfusion
  2. Excess progesterone causing smooth muscle relaxation
  3. Generalised endothelial dysfunction causing vasoconstriction and increased vascular permeability Correct answer.
  4. Increased circulating blood volume causing hypertension

Explanation

Pre-eclampsia is characterised by widespread endothelial dysfunction, which causes vasoconstriction, increased vascular permeability and platelet activation. These changes produce hypertension, proteinuria and potential multi-organ involvement. It is not explained by low cardiac output or excess progesterone.

Question 9Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which placental hormone is primarily responsible for maintaining the corpus luteum in early pregnancy?

  1. Oestriol
  2. Human chorionic gonadotrophin (hCG) Correct answer.
  3. Human placental lactogen (hPL)
  4. Progesterone

Explanation

hCG from the syncytiotrophoblast stimulates the corpus luteum to continue secreting progesterone until the placenta takes over this function at around 8–10 weeks. hPL supports fetal growth and maternal metabolic adaptation, while oestriol is produced later in pregnancy. Progesterone maintains the pregnancy but is the output of the corpus luteum, not the hormone that maintains it.

Question 10Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 38 weeks' gestation reports a sudden gush of clear fluid from the vagina. On examination, the fetal head is at −3 station and the cervix is 2 cm dilated. Which complication is most likely if the membranes have ruptured?

  1. Cord prolapse Correct answer.
  2. Uterine rupture
  3. Placental abruption
  4. Shoulder dystocia

Explanation

When the membranes rupture and the fetal head is high (station −3), the presenting part does not block the pelvic inlet, creating a risk of cord prolapse. This is an obstetric emergency requiring immediate assessment. Abruption, uterine rupture and shoulder dystocia have different mechanisms and are not directly caused by rupture of membranes with a high head.

Question 11Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

During a contraction, which change in fetal heart rate is considered a normal response?

  1. Early decelerations that mirror the contraction Correct answer.
  2. Variable decelerations lasting more than 60 seconds
  3. A baseline tachycardia of 170 beats per minute
  4. Late decelerations that begin after the contraction

Explanation

Early decelerations are a benign, vagally mediated response to head compression during contractions and mirror the contraction in timing and shape. They are not associated with fetal hypoxia. Late decelerations, prolonged variable decelerations and baseline tachycardia are non-reassuring patterns requiring further assessment.

Question 12Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which change in the maternal respiratory system occurs during pregnancy?

  1. Haemoglobin concentration increases significantly
  2. Arterial partial pressure of carbon dioxide rises above 45 mmHg
  3. Tidal volume increases while functional residual capacity decreases Correct answer.
  4. Respiratory rate falls below 10 breaths per minute

Explanation

Progesterone stimulates the respiratory centre, increasing tidal volume by about 40% and raising minute ventilation. Functional residual capacity falls as the enlarging uterus elevates the diaphragm. This mild hyperventilation lowers maternal carbon dioxide, which facilitates fetal gas exchange.

Question 13Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 36 weeks' gestation has a fetus in a persistent occipitoposterior position. Which finding is most characteristic of this position during labour?

  1. A contraction pattern of 2 minutes' duration with 5-minute intervals
  2. Early rupture of membranes with a gush of fluid
  3. Rapid descent of the fetal head through the pelvis
  4. Back pain that is more intense than abdominal pain Correct answer.

Explanation

In an occipitoposterior position, the fetal occiput presses against the maternal sacrum, causing intense back pain that often predominates over abdominal pain. Labour may be slower and descent less efficient. This position does not typically cause early membrane rupture or unusually long contractions.

Question 14Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which physiological change in the cardiovascular system occurs immediately after birth?

  1. A fall in systemic vascular resistance
  2. A rise in pulmonary vascular resistance
  3. Continued flow through the ductus arteriosus
  4. Closure of the foramen ovale due to increased left atrial pressure Correct answer.

Explanation

With the first breaths, pulmonary vascular resistance falls and pulmonary blood flow increases, raising left atrial pressure. This reverses the pressure gradient across the foramen ovale, functionally closing it. Systemic vascular resistance rises after the umbilical cord is clamped, and the ductus arteriosus constricts rather than remains open.

Question 15Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 32 weeks' gestation has a haemoglobin of 95 g/L with a mean corpuscular volume of 70 fL. Which is the most likely cause?

  1. Folate deficiency anaemia
  2. Vitamin B12 deficiency anaemia
  3. Iron deficiency anaemia Correct answer.
  4. Physiological haemodilution of pregnancy

Explanation

A low haemoglobin with a low mean corpuscular volume (microcytosis) suggests iron deficiency, which is common in pregnancy due to increased iron requirements. Physiological haemodilution typically produces a normocytic picture with haemoglobin rarely below 100 g/L. Folate and B12 deficiencies cause macrocytic anaemia.

Question 16Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which mechanism best explains the increased risk of thromboembolism in pregnancy?

  1. Hypercoagulability from increased clotting factors and reduced fibrinolysis Correct answer.
  2. A decrease in platelet aggregation
  3. Reduced venous stasis due to increased mobility
  4. Lower levels of fibrinogen in the third trimester

Explanation

Pregnancy induces a hypercoagulable state with rises in factors VII, VIII, IX, X and fibrinogen, alongside reduced fibrinolysis. Venous stasis also increases as the uterus compresses the pelvic veins. These changes persist into the postnatal period and underlie the elevated thromboembolic risk.

Question 17Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

During the third stage of labour, which process leads to separation of the placenta?

  1. Dilation of the cervix to 10 cm
  2. Shearing of the placenta from the decidua basalis as the uterus contracts and retracts Correct answer.
  3. Active contraction of the umbilical cord
  4. Relaxation of the uterine muscle

Explanation

After birth, the uterus contracts and retracts, reducing the placental site and causing the placenta to shear off the decidua basalis. This separation is followed by expulsion of the placenta and membranes. Uterine relaxation would promote bleeding, not separation.

Question 18Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A newborn at 1 minute of age has a heart rate of 120 beats per minute, a strong cry, some flexion of the limbs, a grimace when stimulated, and blue extremities with a pink body. What Apgar score should be assigned?

  1. 8 Correct answer.
  2. 10
  3. 9
  4. 7

Explanation

The Apgar score assigns 0, 1 or 2 for each of five components. Here heart rate above 100 scores 2, respiratory effort (strong cry) scores 2, muscle tone (some flexion) scores 1, reflex irritability (grimace) scores 1, and colour (acrocyanosis) scores 1, giving a total of 7. A score of 7 is not the same as 8, which would require fully flexed tone or completely pink colour.

Question 19Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which fetal presentation is associated with the highest risk of cord prolapse at the time of membrane rupture?

  1. Breech presentation with a flexed head
  2. Cephalic presentation with the head engaged
  3. Transverse lie Correct answer.
  4. Occipitoanterior position

Explanation

In a transverse lie, the fetal presenting part does not occlude the pelvic inlet, leaving space for the umbilical cord to prolapse when the membranes rupture. Cephalic presentation with an engaged head and most breech presentations provide some occlusion. Occipitoanterior position is a normal cephalic presentation and carries low risk.

Question 20Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which hormonal event initiates lactation after birth?

  1. A fall in prolactin levels after placental delivery
  2. A fall in progesterone allowing prolactin to stimulate milk synthesis Correct answer.
  3. An increase in progesterone supporting milk ejection
  4. A rise in oestrogen stimulating alveolar growth

Explanation

After delivery of the placenta, progesterone levels fall sharply, removing inhibition of prolactin receptors in the breast. Prolactin then drives milk synthesis (lactogenesis II). Oestrogen and progesterone support mammary development during pregnancy but block full milk production until their levels fall.

Question 21Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 28 weeks' gestation has a random plasma glucose of 9.5 mmol/L. Which pathophysiological change of pregnancy contributes to gestational diabetes?

  1. Increased insulin resistance mediated by placental hormones Correct answer.
  2. Increased hepatic gluconeogenesis
  3. Reduced maternal insulin secretion
  4. Enhanced peripheral glucose uptake

Explanation

Placental hormones such as human placental lactogen and progesterone increase maternal insulin resistance, especially in the second and third trimesters. When pancreatic beta cells cannot meet the increased insulin demand, gestational diabetes develops. Reduced insulin secretion or enhanced glucose uptake would lower, not raise, blood glucose.

Question 22Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which change in renal function is expected during normal pregnancy?

  1. Serum creatinine rises above 100 µmol/L
  2. Renal plasma flow decreases by 30%
  3. Proteinuria of 2+ on dipstick becomes normal
  4. Glomerular filtration rate increases by approximately 50% Correct answer.

Explanation

Renal blood flow and glomerular filtration rate increase by about 50% in pregnancy to clear fetal waste products. As a result, serum creatinine and urea fall below non-pregnant values. Significant proteinuria is never a normal finding and requires investigation.

Question 23Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 20 weeks' gestation reports dark, concentrated urine and reduced frequency. Which physiological change of pregnancy could contribute to this?

  1. Increased glomerular filtration rate causing polyuria
  2. A rise in serum creatinine
  3. Compression of the renal arteries by the uterus
  4. Dilatation of the ureters and reduced bladder tone due to progesterone Correct answer.

Explanation

Progesterone relaxes ureteric and bladder smooth muscle, leading to ureteric dilatation and urinary stasis. This can predispose to urinary tract infections, which may present with dark, concentrated urine and reduced frequency. Increased filtration would promote urine output, not reduce it.

Question 24Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which statement about the physiology of the fetal heart rate is correct?

  1. The fetal heart rate is controlled primarily by the placenta
  2. The fetal heart rate is influenced by the autonomic nervous system and baroreceptors Correct answer.
  3. The fetal heart rate is normally lower than the maternal heart rate
  4. Fetal heart rate variability is absent during normal sleep cycles

Explanation

The fetal heart rate is regulated by the sympathetic and parasympathetic nervous systems, as well as baroreceptors and chemoreceptors that respond to changes in blood pressure and oxygenation. Normal variability reflects an intact autonomic nervous system. The placenta does not control the fetal heart rate.

Question 25Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 12 weeks' gestation has a uterus that is palpable above the symphysis pubis. Which anatomical change explains this finding?

  1. The ovaries enlarge and lift the uterus
  2. The uterus remains a pelvic organ until 20 weeks
  3. The uterus becomes an abdominal organ as it grows and rises out of the pelvis Correct answer.
  4. The cervix dilates to accommodate the fetus

Explanation

By about 12 weeks' gestation, the uterus has grown sufficiently to be palpable above the symphysis pubis as it rises into the abdomen. It typically reaches the umbilicus at around 20 weeks. Cervical dilation and ovarian enlargement do not explain this finding.

Question 26Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which structure produces progesterone to sustain the pregnancy after the corpus luteum regresses at around 8 to 10 weeks' gestation?

  1. The placental syncytiotrophoblast Correct answer.
  2. The decidua parietalis
  3. The myometrial smooth muscle
  4. The amniotic epithelium

Explanation

The syncytiotrophoblast of the placenta takes over progesterone production from the corpus luteum by about 8 to 10 weeks, a shift known as the luteoplacental shift. This progesterone maintains the endometrium and quiesces myometrial activity.

Question 27Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman in the second stage of labour has a fetal heart rate baseline of 140 beats per minute with accelerations. Which feature of the cardiotocograph most reliably reflects intact fetal autonomic function?

  1. A baseline rate of 140 beats per minute
  2. Accelerations of 15 beats per minute for 15 seconds Correct answer.
  3. Baseline variability of 5 beats per minute
  4. Absence of decelerations

Explanation

Accelerations reflect sympathetic and parasympathetic responsiveness of the fetal autonomic nervous system and are a reassuring sign of fetal wellbeing. Reduced variability or absence of accelerations warrants closer assessment even when the baseline rate is normal.

Question 28Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which anatomical feature of the fetal circulation allows oxygenated blood from the umbilical vein to bypass the hepatic sinusoids and reach the inferior vena cava?

  1. The foramen ovale
  2. The ductus venosus Correct answer.
  3. The ductus arteriosus
  4. The umbilical arteries

Explanation

The ductus venosus shunts well-oxygenated blood from the umbilical vein directly into the inferior vena cava, bypassing the liver. The foramen ovale and ductus arteriosus are later shunts within the heart and great vessels.

Question 29Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 30 weeks' gestation has a fundal height of 34 cm and a history of polyhydramnios. Which pathophysiological consequence of polyhydramnios is most likely to affect her labour?

  1. Overdistension of the uterus predisposing to postpartum haemorrhage Correct answer.
  2. Increased risk of fetal growth restriction
  3. Reduced risk of cord prolapse
  4. Premature closure of the ductus arteriosus

Explanation

Excessive amniotic fluid overdistends the myometrium, impairing its ability to contract effectively after delivery and increasing the risk of postpartum haemorrhage. Polyhydramnios is also associated with malpresentation and cord prolapse rather than protection from them.

Question 30Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which change in gastrointestinal physiology during pregnancy best explains the increased incidence of constipation?

  1. Reduced circulating blood volume concentrating bowel contents
  2. Shortening of the large intestine by uterine enlargement
  3. Increased gastric acid secretion accelerating digestion
  4. Progesterone-mediated relaxation of smooth muscle slowing intestinal transit Correct answer.

Explanation

High progesterone levels relax gastrointestinal smooth muscle and reduce peristalsis, prolonging transit time and promoting water reabsorption. This, together with iron supplementation and reduced physical activity, contributes to constipation.

Question 31Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 35 weeks' gestation has a fetus in a frank breech presentation. Which mechanism during labour most commonly allows the breech to be born vaginally?

  1. Extension of the fetal head before the buttocks enter the pelvis
  2. Rotation of the buttocks to the transverse diameter before descent
  3. Descent of the breech with lateral flexion of the fetal trunk Correct answer.
  4. Delivery of the head before the shoulders

Explanation

In a frank breech, the buttocks descend and the trunk flexes laterally so that the anterior buttock leads, followed by the shoulders and finally the head. The head should remain flexed until it reaches the pelvic floor, where it undergoes flexion and then extension for delivery.

Question 32Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 33 weeks' gestation presents with a blood pressure of 165/110 mmHg, hyperreflexia and a platelet count of 85 x 10^9/L. Which pathophysiological mechanism best explains these findings?

  1. Isolated hyperaldosteronism causing sodium retention
  2. Autoimmune destruction of platelets in the spleen
  3. Generalised endothelial dysfunction with vasoconstriction and platelet consumption Correct answer.
  4. Primary cardiac failure reducing renal perfusion

Explanation

Pre-eclampsia involves widespread endothelial dysfunction that causes vasoconstriction, hypertension and platelet activation with consumption. Hyperreflexia reflects cerebral oedema and irritability, a sign of severe disease.

Question 33Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which physiological adaptation of the newborn circulation occurs immediately after birth as pulmonary vascular resistance falls?

  1. Closure of the foramen ovale due to reversal of the atrial pressure gradient Correct answer.
  2. Constriction of the pulmonary arterioles
  3. Opening of the ductus arteriosus
  4. Closure of the ductus venosus due to increased umbilical blood flow

Explanation

With the first breaths, pulmonary vascular resistance falls and pulmonary blood flow increases, raising left atrial pressure above right atrial pressure. This reverses the atrial pressure gradient and functionally closes the foramen ovale.

Question 34Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 26 weeks' gestation has a normal glucose tolerance test but reports recurrent hypoglycaemic symptoms between meals. Which physiological change of pregnancy explains this?

  1. Enhanced insulin secretion with increased insulin sensitivity
  2. Reduced hepatic glucose output due to placental lactogen
  3. Increased peripheral glucose uptake due to rising insulin resistance
  4. Accelerated fasting gluconeogenesis with reduced insulin sensitivity Correct answer.

Explanation

Pregnancy is characterised by progressive insulin resistance driven by placental hormones, and fasting glucose levels fall as glucose is diverted to the fetus. Accelerated fasting and hypoglycaemia between meals are common consequences.

Question 35Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

A woman at 18 weeks' gestation has a uterus palpable at the umbilicus. Which anatomical explanation best accounts for this finding?

  1. The uterus rises out of the pelvis as it enlarges and displaces the bladder anteriorly Correct answer.
  2. The uterus remains within the pelvis until 24 weeks
  3. The cervix lengthens and elevates the uterus
  4. The round ligaments shorten and pull the uterus upwards

Explanation

By about 20 weeks the uterus reaches the level of the umbilicus as it enlarges and rises out of the pelvis. It also displaces the bladder anteriorly and the bowel laterally.

Question 36Midwifery knowledge: anatomy, physiology and pathophysiology of pregnancy, labour, birth and the postnatal period

Which change in maternal calcium homeostasis occurs during pregnancy to meet fetal skeletal demands?

  1. Reduced renal calcium reabsorption
  2. Increased intestinal calcium absorption mediated by calcitriol Correct answer.
  3. Suppression of parathyroid hormone secretion
  4. Decreased maternal plasma volume

Explanation

Pregnancy increases 1,25-dihydroxyvitamin D (calcitriol) activity, which enhances intestinal calcium absorption to supply the fetus. Maternal parathyroid hormone is not suppressed and renal calcium handling is adjusted to conserve calcium.

Question 37Antenatal care and assessment, including screening and risk identification

A pregnant woman at 28 weeks' gestation has a symphysis-fundal height of 24 cm. What is the most appropriate interpretation and action for a midwife in New Zealand?

  1. The measurement is within normal range and no action is required
  2. The measurement should be repeated in 4 weeks before any concern is raised
  3. The measurement is 4 cm below gestation and warrants referral for a growth scan Correct answer.
  4. The measurement indicates oligohydramnios and immediate induction is needed

Explanation

Symphysis-fundal height should broadly correlate with gestational age in centimetres from around 20 to 36 weeks, and a discrepancy of 3 cm or more warrants further assessment. A 4 cm shortfall at 28 weeks should prompt referral for ultrasound assessment of fetal growth and liquor volume.

Question 38Antenatal care and assessment, including screening and risk identification

Which laboratory finding in early pregnancy most strongly indicates the need to screen for gestational diabetes with an early glucose tolerance test?

  1. Previous spontaneous vaginal birth
  2. Booking body mass index of 35 kg/m² Correct answer.
  3. Haemoglobin 105 g/L at 12 weeks
  4. Blood group O rhesus negative

Explanation

A booking BMI of 30 kg/m² or above is an established risk factor prompting early screening for gestational diabetes in New Zealand pathways. Anaemia, blood group and previous uncomplicated birth do not independently trigger early glucose testing.

Question 39Antenatal care and assessment, including screening and risk identification

A woman books at 10 weeks and reports she has never had a cervical screening test. What is the midwife's most appropriate response within antenatal care?

  1. Advise that cervical screening should wait until after the pregnancy and note for follow-up Correct answer.
  2. Reassure her that antenatal care does not include cervical screening discussions
  3. Arrange cervical screening during this pregnancy as part of booking
  4. Refer urgently for colposcopy regardless of screening history

Explanation

Cervical screening is generally deferred during pregnancy unless there are abnormal symptoms, and the midwife should document the overdue status and prompt screening postpartum. Routine screening in pregnancy is not part of standard antenatal care, but the opportunity for health promotion should not be lost.

Question 40Antenatal care and assessment, including screening and risk identification

At the first antenatal visit, which history finding most increases the risk of pre-eclampsia and warrants low-dose aspirin discussion?

  1. Family history of type 2 diabetes
  2. Mild asthma controlled with inhalers
  3. First pregnancy at age 24
  4. Previous pre-eclampsia requiring preterm birth Correct answer.

Explanation

A history of pre-eclampsia, particularly with preterm delivery, is a high-risk factor for recurrence and meets criteria for aspirin prophylaxis. Nulliparity at a young age is only a modest risk factor and does not alone justify aspirin.

Question 41Antenatal care and assessment, including screening and risk identification

What is the primary purpose of the first-trimester combined screening offered in New Zealand?

  1. To estimate the chance of trisomy 21, 18 and 13 and offer diagnostic testing if indicated Correct answer.
  2. To detect structural fetal anomalies at 11 weeks
  3. To determine fetal sex for clinical management
  4. To diagnose chromosomal conditions definitively

Explanation

First-trimester combined screening uses maternal age, nuchal translucency and serum markers to estimate risk, not to diagnose. Women with a high chance result are offered diagnostic testing such as amniocentesis or CVS.

Question 42Antenatal care and assessment, including screening and risk identification

A woman at 34 weeks reports a sudden reduction in fetal movements over the past 24 hours. What is the correct midwifery action?

  1. Arrange urgent assessment with CTG and obstetric review the same day Correct answer.
  2. Schedule a routine growth scan at her next appointment
  3. Reassure her that movements naturally reduce in late pregnancy
  4. Advise her to lie on her left side and count movements for 24 hours

Explanation

Reduced fetal movements after 28 weeks require same-day assessment with auscultation or CTG and obstetric review, because they may signal fetal compromise. Women should never be advised to simply wait or count for a prolonged period.

Question 43Antenatal care and assessment, including screening and risk identification

Which measurement is used in New Zealand to assess fetal growth at the anatomy scan and later surveillance?

  1. Crown-rump length
  2. Abdominal circumference and estimated fetal weight Correct answer.
  3. Biparietal diameter alone
  4. Nuchal translucency thickness

Explanation

Abdominal circumference and estimated fetal weight are the key parameters for detecting growth restriction and monitoring fetal growth. Biparietal diameter and crown-rump length are useful in earlier dating but not for growth surveillance.

Question 44Antenatal care and assessment, including screening and risk identification

A woman is rhesus negative and has a negative antibody screen at booking. When should anti-D immunoglobulin be offered as routine prophylaxis?

  1. At 28 and 34 weeks, and after any sensitising event Correct answer.
  2. Only after delivery if the baby is rhesus positive
  3. At 20 weeks only
  4. At booking only

Explanation

Routine antenatal anti-D prophylaxis in New Zealand is given around 28 and 34 weeks, with additional doses after potentially sensitising events such as bleeding or procedures. Postnatal anti-D is also given if the baby is rhesus positive, but antenatal cover is standard.

Question 45Antenatal care and assessment, including screening and risk identification

A woman at 38 weeks has a blood pressure of 150/100 mmHg on two occasions four hours apart with 2+ proteinuria. What is the most appropriate immediate action?

  1. Arrange urgent obstetric assessment for possible pre-eclampsia Correct answer.
  2. Document as normal pregnancy variation
  3. Advise rest at home and recheck in one week
  4. Recommend increased salt intake

Explanation

New hypertension with proteinuria after 20 weeks suggests pre-eclampsia and requires urgent obstetric assessment, including blood tests and fetal monitoring. Delay risks progression to severe disease or eclampsia.

Question 46Antenatal care and assessment, including screening and risk identification

Which finding on the 20-week anatomy scan most strongly warrants referral to a maternal-fetal medicine specialist?

  1. Placenta located anteriorly
  2. Mild pyelectasis resolving on repeat
  3. Fetal cardiac anomaly suspected Correct answer.
  4. Single umbilical artery with normal growth

Explanation

A suspected structural cardiac anomaly requires specialist fetal medicine and cardiology review for confirmation and birth planning. Anterior placenta and isolated mild findings with normal growth are usually followed with routine surveillance.

Question 47Antenatal care and assessment, including screening and risk identification

A woman with a BMI of 42 kg/m² books at 9 weeks. Which antenatal consideration is most important for the midwife to address?

  1. Restricting all antenatal ultrasound
  2. Referral for specialist obstetric care and discussion of thromboprophylaxis risk Correct answer.
  3. Routine induction at 36 weeks
  4. Advising weight loss of 10 kg during pregnancy

Explanation

Severe obesity increases risks of thromboembolism, gestational diabetes, pre-eclampsia and complications, so referral for specialist care and risk assessment including VTE is appropriate. Weight loss during pregnancy is not advised, and care should be individualised.

Question 48Antenatal care and assessment, including screening and risk identification

What is the recommended timing for the anatomy scan in an uncomplicated pregnancy in New Zealand?

  1. Around 18 to 20 weeks Correct answer.
  2. Around 12 weeks
  3. Around 32 weeks
  4. Around 24 weeks

Explanation

The anatomy scan is performed around 18 to 20 weeks when fetal structures are well visualised and dating is established. Earlier scans are for dating and screening, and later scans are for growth.

Question 49Antenatal care and assessment, including screening and risk identification

A woman reports a history of a previous baby with a neural tube defect. What antenatal recommendation is most appropriate?

  1. Routine low-dose folic acid only
  2. High-dose folic acid supplementation from before conception through the first trimester Correct answer.
  3. No additional supplementation beyond diet
  4. Immediate referral for fetal surgery

Explanation

A previous affected pregnancy is an indication for high-dose folic acid (5 mg daily) started before conception and continued into the first trimester to reduce recurrence risk. Standard low-dose supplementation is insufficient in this situation.

Question 50Antenatal care and assessment, including screening and risk identification

Which symptom reported at 26 weeks should prompt immediate assessment for possible venous thromboembolism?

  1. Mild ankle swelling at the end of the day
  2. Unilateral calf pain and swelling Correct answer.
  3. Lower back ache after standing
  4. Occasional heartburn

Explanation

Unilateral calf pain and swelling raise suspicion of deep vein thrombosis, which is more common in pregnancy and requires urgent assessment. Bilateral mild swelling and reflux are common and usually benign.