Ethiopian Midwifery University Exit Exam Practice Questions (50 Items)

Part 1: Antepartum Care (Prenatal Care)

Q1. A 24-year-old primigravida woman at 12 weeks of gestation presents to the antenatal clinic for her first routine visit. Which of the following trace mineral supplements is universally recommended by the Ethiopian National Guidelines to prevent neural tube defects, and what is the standard prophylactic dose? A) Iron 60 mg daily B) Folic acid 0.4 mg daily C) Calcium 1000 mg daily D) Zinc 15 mg daily

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• Correct Answer: B
• Rationale: Prophylactic supplementation of 0.4 mg of folic acid daily during the preconception period and early first trimester is the global and national standard to dramatically reduce the incidence of fetal neural tube defects.

Q2. During a routine antenatal assessment of a woman at 26 weeks of gestation, the midwife observes that the fundal height matches 32 weeks. An ultrasound confirms an amniotic fluid index (AFI) of 26 cm. How should the midwife document this condition, and what is a common maternal etiology? A) Oligohydramnios; Maternal dehydration B) Polyhydramnios; Maternal Diabetes Mellitus C) Normal amniotic volume; Twin gestation D) Borderline fluid volume; Placental insufficiency

• Correct Answer: B
• Rationale: An Amniotic Fluid Index (AFI) greater than 24 cm or a single deepest pocket greater than 8 cm defines polyhydramnios. Poorly controlled maternal diabetes mellitus is a classic cause due to fetal hyperglycemia inducing fetal polyuria.

Q3. A 28-year-old multigravida woman at 34 weeks of gestation presents with a blood pressure of 160/110 mmHg on two separate readings 4 hours apart. A 24-hour urine collection shows 3.5 grams of protein. She complains of persistent epigastric pain and blurred vision. What is the definitive diagnosis? A) Gestational Hypertension B) Preeclampsia without severe features C) Preeclampsia with severe features D) Chronic Hypertension with superimposed preeclampsia

• Correct Answer: C
• Rationale: Preeclampsia is diagnosed by new-onset hypertension after 20 weeks with proteinuria. The presence of a blood pressure ≥160/110 mmHg or severe features like epigastric pain and visual disturbances classifies it as preeclampsia with severe features.

Q4. A pregnant woman at 20 weeks of gestation presents for a routine antenatal checkup. The midwife wants to estimate the fetal gestational age by symphysis-fundal height (SFH) measurement. Where should the midwife expect to palpate the uterine fundus normally at this gestational age? A) At the upper border of the symphysis pubis B) Midway between the symphysis pubis and the umbilicus C) At the exact level of the umbilicus or 1-2 cm below it D) Midway between the umbilicus and the xiphoid process

• Correct Answer: C
• Rationale: Around 20 to 22 weeks of gestation, the top of the uterine fundus typically reaches the level of the maternal umbilicus.

Q5. A 30-year-old pregnant woman at 16 weeks of gestation presents with a history of recurrent spontaneous second-trimester miscarriages. She reports a sudden, painless cervical dilation accompanied by bulging membranes before each previous loss. What condition is suggested? A) Ectopic pregnancy B) Cervical insufficiency (Incompetence) C) Threatened abortion D) Hydatidiform mole

• Correct Answer: B
• Rationale: Cervical insufficiency is characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, presenting typically as painless cervical dilation and effacement.

Q6. A midwife performs Leopold’s maneuvers on a pregnant woman at 37 weeks of gestation. During the first maneuver, the midwife palpates a soft, broad, non-ballottable mass in the fundus. During the second maneuver, a smooth, hard resistance is felt on the maternal left side. What is the fetal presentation and position? A) Breech presentation, Left Occipito-Anterior B) Cephalic presentation, Left Sacro-Anterior C) Cephalic presentation, Left Occipito-Transverse D) Cephalic presentation, Left Sacro-Posterior

• Correct Answer: C
• Rationale: Palpating a soft, broad mass in the fundus implies the breech is at the fundus, meaning the presentation is cephalic. Smooth resistance on the left indicates the fetal back is on the left side, confirming a left-sided orientation.

Q7. A multigravida woman at 32 weeks of gestation presents to the emergency unit with sudden, painless, bright red vaginal bleeding. Her abdomen is soft, relaxed, and non-tender. Fetal heart sounds are normal at 140 beats per minute. Which condition should the midwife suspect first? A) Abruptio Placentae B) Placenta Previa C) Uterine Rupture D) Marginal Decidual Hematoma

• Correct Answer: B
• Rationale: Placenta previa characteristically manifests as sudden, painless, bright red vaginal bleeding in the third trimester with a soft, non-tender uterus. Abruptio placentae presents with painful bleeding and a rigid, tender uterus.

Q8. A primigravida patient at 28 weeks of gestation is diagnosed with Gestational Diabetes Mellitus (GDM) after a 75g oral glucose tolerance test. Which of the following is the primary first-line therapeutic intervention recommended for managing blood glucose levels in GDM? A) Immediate initiation of regular subcutaneous Insulin B) Oral Metformin therapy C) Medical nutritional therapy (Dietary modification) and structured physical exercise D) Continuous intravenous glucose-insulin infusion

• Correct Answer: C
• Rationale: Nutritional counseling, dietary modifications, and moderate lifestyle physical activity are the foundational first-line treatments for GDM. Pharmacological therapies are added only if target glucose levels are not achieved.

Q9. An Rh-negative unsensitized pregnant woman at 28 weeks of gestation attends the antenatal clinic. Her partner is Rh-positive. To prevent Rh isoimmunization, when should the midwife plan to administer Rho(D) immune globulin (RhoGAM)? A) Within 24 hours of her current visit only B) Prophylactically at 28 weeks of gestation and again within 72 hours post-delivery if the newborn is Rh-positive C) At the onset of the second stage of active labor D) Only if she undergoes an emergency operative delivery

• Correct Answer: B
• Rationale: Standard protocol for preventing Rh isoimmunization dictates giving a prophylactic dose of Rho(D) immune globulin at 28 weeks of gestation and a postpartum dose within 72 hours of birth if the neonate is confirmed to be Rh-positive.

Q10. A 19-year-old pregnant woman at 10 weeks of gestation presents with severe, intractable vomiting, a 6 kg weight loss, and postural hypotension. Urinalysis reveals 3+ ketonuria. What is the primary diagnosis? A) Physiological morning sickness B) Hyperemesis Gravidarum C) Acute viral hepatitis D) Gestational trophoblastic disease

• Correct Answer: B
• Rationale: Hyperemesis gravidarum is a severe form of morning sickness characterized by persistent vomiting, weight loss (>5% of pre-pregnancy weight), dehydration, electrolyte imbalances, and ketonuria.

Q11. A midwife is reviewing the laboratory results of a pregnant woman at 24 weeks of gestation. The hemoglobin level is 9.5 g/dL. According to the World Health Organization (WHO) criteria for pregnant women, how should this anemia be classified? A) Mild Anemia B) Moderate Anemia C) Severe Anemia D) Normal physiologic hemodilution

• Correct Answer: B
• Rationale: In pregnant women, anemia is defined as hemoglobin <11.0 g/dL. It is sub-classified as mild (10.0–10.9 g/dL), moderate (7.0–9.9 g/dL), and severe (<7.0 g/dL).

Q12. A G2P1 woman at 36 weeks of gestation presents to the clinic with generalized itching, which is most severe on the palms of her hands and soles of her feet. She has no skin rashes. Laboratory tests show elevated serum bile acids and mild transaminasemia. What condition does this represent? A) Intrahepatic Cholestasis of Pregnancy (ICP) B) Acute Fatty Liver of Pregnancy C) Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) D) Gestational Pemphigoid

• Correct Answer: A
• Rationale: ICP characteristically presents in the third trimester with intense pruritus favoring the palms and soles without a primary rash, driven by elevated circulating serum bile acids.

Q13. A 26-year-old pregnant woman at 38 weeks of gestation is admitted with a history of sudden-onset severe, constant abdominal pain, dark vaginal bleeding, and uterine tenderness. On examination, the uterus is hypertonic and board-like. Fetal heart rate is 100 beats per minute with late decelerations. What is the immediate diagnosis? A) Placenta previa B) Abruptio Placentae C) Circumvallate placenta D) Vasa previa

• Correct Answer: B
• Rationale: Premature separation of a normally implanted placenta (abruptio placentae) classically causes painful vaginal bleeding, uterine rigidity/tenderness, hypertonicity, and signs of fetal distress.

Q14. A client at 8 weeks of gestation by last menstrual period presents with cramping lower abdominal pain and moderate vaginal bleeding. Pelvic examination reveals that the cervical os is closed, and ultrasound demonstrates a viable intrauterine fetus. What type of abortion is this? A) Inevitable abortion B) Threatened abortion C) Incomplete abortion D) Missed abortion

• Correct Answer: B
• Rationale: A threatened abortion is defined by vaginal bleeding and cramping in early pregnancy where the cervical os remains closed and the fetus is alive and viable. In an inevitable abortion, the cervical os is dilated.

Q15. A 34-year-old multigravida woman at 20 weeks of gestation undergoes a routine anomaly ultrasound screen. The scan reveals a completely dilated cervix with herniation of the amniotic sac into the vagina without any uterine contractions. What management is indicated if eligible? A) Absolute bed rest for the remainder of the pregnancy B) Emergency or rescue cervical cerclage placement C) High-dose intravenous Oxytocin infusion D) Administration of prophylactic Tocolytic therapy

• Correct Answer: B
• Rationale: For women presenting with painless advanced cervical dilation and bulging membranes in the second trimester without labor, an emergency or rescue cerclage can safely prolong the pregnancy if infection and labor are ruled out.

Q16. A pregnant woman at 30 weeks of gestation presents with a history of systemic lupus erythematosus (SLE). She is at an increased risk for which of the following specific fetal cardiac complications? A) Tetralogy of Fallot B) Transposition of the great arteries C) Congenital complete heart block D) Ventricular septal defect

• Correct Answer: C
• Rationale: Maternal autoimmune diseases, particularly those involving anti-SSA/Ro and anti-SSB/La antibodies (like SLE), are strongly linked to the development of congenital complete heart block in the fetus.

Q17. During an antenatal booking visit, a midwife screens a pregnant woman for HIV infection using the national rapid test algorithm. The first screening test is reactive. What is the correct next step according to the national guidelines? A) Immediately start life-long Antiretroviral Therapy (ART) B) Perform a confirmatory HIV rapid test using the second test kit in the national algorithm C) Wait for 3 months and repeat the screening test D) Order a CD4 count and viral load immediately without further testing

• Correct Answer: B
• Rationale: The national HIV testing guidelines mandate that a reactive initial rapid screening test must be validated by a second, different confirmatory rapid test before a definitive diagnosis of HIV infection is established.

Q18. A 22-year-old primigravida woman at 35 weeks of gestation presents with preeclampsia with severe features. The midwife receives an order to initiate Magnesium Sulfate therapy for seizure prophylaxis. Which of the following parameters must be assessed and verified as normal before administering each maintenance dose of Magnesium Sulfate? A) Serum calcium level, blood glucose, and bowel sounds B) Patellar reflex present, respiratory rate ≥16 breaths/minute, and urine output ≥30 mL/hour C) Pupillary light reflex, skin turgor, and temperature D) Heart rate ≥100 beats/minute, blood pressure, and mental status

• Correct Answer: B
• Rationale: Magnesium sulfate is cleared by the kidneys. To safely prevent toxicity, the midwife must confirm that deep tendon reflexes are intact, the respiratory rate is not depressed (≥12−16/min), and renal clearance is adequate (≥30 mL/hr).

Q19. A pregnant woman at 28 weeks of gestation is diagnosed with a primary Syphilis infection during a routine VDRL/RPR screening. What is the gold-standard drug of choice recommended to treat maternal syphilis and prevent congenital syphilis in the fetus? A) Oral Azithromycin 1 g single dose B) Intramuscular Benzathine Penicillin G 2.4 million units C) Intravenous Ceftriaxone 1 g daily for 10 days D) Oral Doxycycline 100 mg twice daily for 14 days

• Correct Answer: B
• Rationale: Parenteral Benzathine Penicillin G is the only documented highly effective agent for treating maternal syphilis and crossing the placenta to cure or prevent congenital syphilis. Doxycycline is contraindicated in pregnancy.

Q20. A 29-year-old pregnant woman at 39 weeks of gestation presents for her routine antenatal checkup. She reports experiencing regular, dull lower back discomfort that radiates to the lower abdomen every 15 to 20 minutes. On digital pelvic examination, the cervix is found to be posterior, thick, firm, and completely closed. How should the midwife interpret these findings? A) Active phase of first stage of labor B) True labor contractions C) False labor (Braxton Hicks contractions) D) Latent phase of labor

• Correct Answer: C
• Rationale: False labor is characterized by irregular or regular abdominal/back discomfort that does not produce progressive cervical effacement or dilation, and the cervix remains unchanged on examination.

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Part 2: Intrapartum Care (Labor and Delivery)

Q21. A woman in labor is admitted to the labor ward. Her cervix is 5 cm dilated, with 3 contractions in 10 minutes, each lasting 35 seconds. According to the updated World Health Organization (WHO) labor care guidelines, at what cervical dilation threshold does the active first stage of labor formally begin? A) 3 cm dilation B) 4 cm dilation C) 5 cm dilation D) 6 cm dilation

• Correct Answer: D
• Rationale: The modern WHO labor care guidelines establish that the active first stage of labor begins at 6 cm cervical dilation for both primiparous and multiparous women, a change designed to prevent unnecessary early interventions.

Q22. A 23-year-old primiparous woman is in the second stage of labor. The fetal head has delivered, and the midwife notes that the fetal chin retracts tightly against the maternal perineum (the “turtle sign”). Gentle traction fails to deliver the anterior shoulder. What is the midwife’s immediate priority action? A) Apply sustained, forceful fundal pressure B) Call for emergency assistance and perform the McRoberts maneuver (hyperflexion of maternal thighs) with suprapubic pressure C) Perform an immediate midline episiotomy extending into the rectum D) Attempt to rotate the fetal head manually by 180 degrees

• Correct Answer: B
• Rationale: The “turtle sign” indicates shoulder dystocia. The initial corrective steps are the McRoberts maneuver along with focused suprapubic pressure to dislodge the impacted shoulder from behind the symphysis pubis. Fundal pressure is strictly contraindicated.

Q23. A midwife is monitoring a woman in labor using a partograph. The cervical dilation curve crosses the action line. What does this finding signify, and what is the appropriate midwifery action? A) Normal labor progression; continue routine intermittent monitoring B) Precipitate labor; prepare for an immediate delivery C) Prolonged/Obstructed labor; report to an obstetrician for immediate reassessment and intervention D) False labor; discharge the patient home with analgesics

• Correct Answer: C
• Rationale: When the cervical dilation plotting crosses the action line on a partograph, it indicates abnormally slow progress or protraction, requiring definitive medical evaluation for potential augmentation or operative delivery.

Q24. A G3P2 woman at 40 weeks of gestation is in active labor. Suddenly, she experiences sharp, tearing abdominal pain during a contraction, followed by a complete cessation of uterine contractions. On examination, the midwife notes structural distortion of the abdominal wall, easily palpable fetal parts, and a sudden drop in fetal heart rate. What emergency has occurred? A) Placental abruption B) Uterine inversion C) Complete Uterine Rupture D) Amniotic fluid embolism

• Correct Answer: C
• Rationale: A sudden tearing pain followed by the cessation of contractions, a loss of fetal station, easily palpable fetal parts outside the uterus, and profound fetal bradycardia are diagnostic signs of complete uterine rupture.

Q25. A woman has just delivered a healthy 3.5 kg infant. The midwife immediately initiates the Active Management of the Third Stage of Labor (AMTSL). Which of the following represents the correct sequence and components of AMTSL according to international standards? A) Uterine massage, manual removal of the placenta, and administration of Ergometrine B) Administration of a uterotonic agent (e.g., Oxytocin 10 IU IM), controlled cord traction, and ongoing assessment of uterine tonus C) Immediate cord clamping, maternal bearing down, and fundal pressure D) Waiting for signs of separation, manual traction, and cold packs to the abdomen

• Correct Answer: B
• Rationale: AMTSL consists of three core components: administration of a uterotonic (Oxytocin is first choice) within 1 minute of birth, controlled cord traction (CCT) with counter-traction to deliver the placenta, and continuous massage/assessment of uterine tone.

Q26. During the digital vaginal examination of a laboring woman at 39 weeks of gestation with ruptured membranes, the midwife palpates the orbital ridges, frontal suture, and the anterior fontanelle. The landmark denominator for this presentation is the forehead (frons). What presentation is this? A) Vertex presentation B) Face presentation C) Brow presentation D) Shoulder presentation

• Correct Answer: C
• Rationale: A brow presentation occurs when the fetal head is partially extended, placing the orbital ridges and the anterior fontanelle within reach of the examining fingers.

Q27. A midwife is assessing the electronic fetal monitoring (EFM) strip of a woman in active labor. The strip shows a pattern of fetal heart rate decelerations that are symmetric, gradual, mirror the uterine contractions exactly (beginning with the contraction and returning to baseline as the contraction ends). What is the underlying cause? A) Uteroplacental insufficiency B) Umbilical cord compression C) Fetal head compression causing vagal stimulation D) Maternal hypoxemia

• Correct Answer: C
• Rationale: Early decelerations are benign patterns caused by temporary compression of the fetal head during a contraction, which triggers a vagal reflex that slows the heart rate symmetrically with the contraction.

Q28. A multiparous woman at 38 weeks of gestation is admitted in labor. The membranes rupture spontaneously, and the midwife immediately notes a loop of the umbilical cord protruding through the cervix into the vagina. Fetal heart sounds are regular at 145 bpm. What is the immediate priority intervention? A) Attempt to push the umbilical cord back inside the uterine cavity manually B) Place the woman in the knee-chest or exaggerated Trendelenburg position and manually elevate the presenting part off the cord while arranging an immediate Cesarean section C) Proceed with an immediate instrumental vaginal delivery in the ward D) Administer a high-dose oxytocin infusion to accelerate delivery

• Correct Answer: B
• Rationale: In a cord prolapse emergency, the immediate goal is to relieve mechanical compression on the cord by gravity (repositioning the mother) and manually lifting the presenting part until an emergency surgical delivery can be completed.

Q29. A primigravida woman at 41 weeks of gestation is undergoing labor induction with Oxytocin. The midwife notes that the patient is experiencing 6 uterine contractions in 10 minutes, with each contraction lasting 60 seconds, accompanied by prolonged fetal heart rate decelerations. What complication does this indicate? A) Hypotonic uterine dysfunction B) Uterine tachysystole (Hyperstimulation) C) Normal active labor progression D) Cervical dystocia

• Correct Answer: B
• Rationale: Uterine tachysystole is defined as more than 5 contractions within a 10-minute window, averaged over 30 minutes, which can compromise uteroplacental blood flow and cause fetal distress.

Q30. A midwife is performing a vaginal examination on a client in labor. The midwife notes that the fetal sagittal suture is deflected laterally towards the posterior maternal pelvis, leaving the anterior parietal bone as the predominant presenting surface. What is this clinical phenomenon called? A) Synclitism B) Anterior Asynclitism C) Posterior Asynclitism D) Extension

• Correct Answer: B
• Rationale: Asynclitism occurs when the fetal sagittal suture is not aligned centrally in the birth canal. When the suture is deflected posteriorly, the anterior parietal bone presents first, defining anterior asynclitism.

Q31. During a vaginal delivery, the midwife decides that an episiotomy is necessary due to impending perineal tears. The midwife performs a mediolateral episiotomy. What is the primary anatomical advantage of a mediolateral episiotomy over a median (midline) episiotomy? A) It is much easier to repair and causes significantly less immediate postpartum pain B) It carries a significantly lower risk of extension into the anal sphincter (third- and fourth-degree perineal tears) C) It results in less intraoperative blood loss D) It can be performed safely without local anesthesia

• Correct Answer: B
• Rationale: Mediolateral episiotomies direct the incision away from the perineal body toward the ischial tuberosity, reducing the risk of accidental extension into the rectum or anal sphincter.

Q32. A 28-year-old woman is in the third stage of labor. Twenty minutes after delivery of the baby, the placenta has not yet separated. Which classic clinical sign indicates that placental separation has successfully occurred? A) The uterus elongates, flattens, and becomes soft B) A sudden gush of blood from the vagina, lengthening of the umbilical cord, and the fundus becoming firm and globular C) The umbilical cord retracts upwards into the vagina D) Maternal blood pressure drops significantly

• Correct Answer: B
• Rationale: The classic indicators of placental separation include a fresh gush of blood, lengthening of the visible cord at the vulva, and a change in the uterine shape to firm, hard, and globular as it rises in the abdomen.

Q33. A midwife is managing a vaginal delivery of a singleton fetus in frank breech presentation at 39 weeks. The fetal breech and limbs have delivered. The midwife allows the body to hang naturally to encourage descent. Which specific manual maneuver should the midwife execute to safely facilitate the delivery of the after-coming fetal head? A) Woods’ screw maneuver B) Lovset’s maneuver C) Mauriceau-Smellie-Veit maneuver D) McRoberts maneuver

• Correct Answer: C
• Rationale: The Mauriceau-Smellie-Veit maneuver uses the operator’s fingers inside the fetal mouth and on the malar bones to flex the head, combined with counter-pressure on the occiput, safely delivering the after-coming head in a breech birth.

Q34. A G1P0 woman at 40 weeks is admitted in labor. Her cervix has remained stagnant at 7 cm dilation for the last 4 hours despite having strong, coordinated uterine contractions every 3 minutes. The fetal head is at -2 station, and significant molding is noted. What is the most likely diagnosis? A) Latent phase arrest B) Cephalopelvical Disproportion (CPD) C) Hypotonic labor dysfunction D) Precipitate labor

• Correct Answer: B
• Rationale: Lack of cervical progress in the active phase despite strong, regular contractions, combined with a high fetal station and significant cranial molding, strongly points to a mechanical mismatch or CPD.

Q35. A woman in labor is being evaluated. The midwife determines that the fetal presenting part is at the level of the maternal ischial spines. How should the midwife document this fetal station on the partograph? A) Station -2 B) Station 0 C) Station +1 D) Station +3

• Correct Answer: B
• Rationale: Fetal station describes the descent of the presenting part relative to the maternal ischial spines. At the level of the spines, the station is defined as 0.

Q36. A woman at 39 weeks of gestation with no antenatal complications presents in active labor. Amniotomy is performed at 7 cm dilation, and thick, dark-green particles are noted in the fluid. The fetal heart rate drops to 90 bpm immediately following contractions. What does this indicate? A) Normal amniotic fluid presentation B) Fetal distress secondary to meconium aspiration risk or hypoxia C) Chronic fetal renal failure D) Physiological adaptation to regular labor

• Correct Answer: B
• Rationale: Meconium-stained amniotic fluid along with late decelerations or persistent bradycardia indicates fetal hypoxia, requiring immediate intrauterine resuscitation and a plan for delivery.

Q37. A 32-year-old G4P3 woman has a history of rapid deliveries. She is admitted with intense contractions every 1.5 minutes. Within 2 hours of admission, she delivers a healthy infant. The total duration from labor onset to delivery was 2.5 hours. How should this be classified? A) Protracted active labor B) Precipitate labor C) Prolonged latent labor D) Secondary arrest of descent

• Correct Answer: B
• Rationale: Precipitate labor is defined as rapid labor and delivery that finishes within 3 hours from the onset of regular uterine contractions.

Q38. A midwife is preparing to perform a vaginal examination on a client in labor. Which of the following conditions is an absolute contraindication to a digital vaginal examination during the third trimester of pregnancy? A) Confirmed Pre-labor Rupture of Membranes (PROM) B) Unexplained vaginal bleeding before the placental location is confirmed by ultrasound C) Breech presentation D) Twin gestation in early labor

• Correct Answer: B
• Rationale: Digital examination of a patient with an unknown placental location or known placenta previa can inadvertently detach the placenta, triggering life-threatening maternal hemorrhage.

Q39. A laboring patient’s membranes rupture, and the midwife notes that the fetus is in a transverse lie with a shoulder presentation. Which option represents the safe, definitive delivery method for a live singleton fetus in a fixed transverse lie? A) Forceps-assisted vaginal delivery B) High-dose Oxytocin augmentation C) Emergency Cesarean section D) Internal podalic version during advanced labor

• Correct Answer: C
• Rationale: A persistent transverse lie cannot safely deliver vaginally. Attempting a vaginal birth poses a high risk of uterine rupture and fetal demise, making a Cesarean section the standard of care.

Q40. A woman in labor requests non-pharmacological pain relief. Which of the following simple evidence-based techniques can the midwife implement to safely reduce labor pain and enhance maternal satisfaction? A) Enforcing absolute recumbent immobilization B) Encouraging continuous slow deep breathing techniques, warm compresses, and upright positions C) Restricted oral hydration protocols D) Continuous high-pressure fundal massage

• Correct Answer: B
• Rationale: Upright positions, controlled deep breathing exercises, and warm compresses promote relaxation, maximize pelvic diametric access, and provide effective non-pharmacological comfort during labor.

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Part 3: Postpartum Care (Puerperium)

Q41. A midwife is assessing a client 2 hours after a successful vaginal delivery of a 4.2 kg baby. The midwife notes heavy vaginal bleeding with large clots, and on palpation, the uterine fundus is soft, boggy, and located above the umbilicus. What is the most likely cause of this postpartum hemorrhage (PPH)? A) Perineal laceration B) Uterine Atony C) Retained placental fragments D) Coagulopathy (Thrombin issue)

• Correct Answer: B
• Rationale: Uterine atony (failure of the myometrium to contract effectively after birth) is the most common cause of primary PPH, presenting as a soft, boggy, poorly contracted uterus.

Q42. A postpartum woman on day 4 after delivery complains of painful, swollen, and firm breasts bilaterally. She reports that the baby is having difficulty latching onto the nipple. Her temperature is 37.4°C. What condition does this describe, and what is the primary management? A) Bilateral breast abscess; Surgical drainage B) Acute Mastitis; Immediate cessation of breastfeeding and starting antibiotics C) Breast Engorgement; Frequent on-demand breastfeeding, warm compresses before feeding, and cold compresses after feeding D) Fibroadenoma flare; Supportive brassiere only

• Correct Answer: C
• Rationale: Breast engorgement occurs bilaterally in the early postpartum period due to vascular congestion and milk accumulation. It is managed by optimizing breastfeeding techniques, expressing milk to soften the areola, and using targeted temperature therapies.

Q43. On the third postpartum day following an uncomplicated delivery, the midwife evaluates the maternal vaginal discharge. The discharge is pinkish-brown, composed of serous exudate, erythrocytes, leukocytes, and cervical mucus. How should this lochia be documented? A) Lochia rubra B) Lochia serosa C) Lochia alba D) Lochia purulenta

• Correct Answer: B
• Rationale: Lochia serosa is the pinkish-brown postpartum discharge that typically flows from days 4 to 10, following the bloody lochia rubra (days 1–3) and preceding the yellowish-white lochia alba.

Q44. A 26-year-old postpartum woman presents to the clinic on day 10 post-delivery with a complaints of a high fever (38.9∘C), foul-smelling lochia, and severe lower abdominal pain. On physical assessment, she exhibits marked uterine tenderness. What is the diagnosis? A) Postpartum blues B) Puerperal Endometritis C) Acute Pyelonephritis D) Pelvic hematoma

• Correct Answer: B
• Rationale: Puerperal endometritis is an infection of the uterine lining, characteristically presenting with fever, foul-smelling vaginal discharge, and localized uterine tenderness within the first 10 days postpartum.

Q45. A midwife is caring for a postpartum woman 6 hours after an operative forceps-assisted vaginal delivery. The patient reports escalating, severe, agonizing rectal and perineal pain that is unresponsive to standard analgesics. Her vital signs show tachycardia. On local inspection, the midwife notes a tense, bluish, fluctuant swelling lateral to the vagina. What is the diagnosis? A) Extended third-degree perineal tear B) Vulvovaginal Hematoma C) Hemorrhoidal thrombosis D) Endometritis

• Correct Answer: B
• Rationale: Severe, unremitting perineal pain following an instrumental delivery, paired with a tense, discolored swelling, indicates a vulvovaginal hematoma caused by hidden vascular injury.

Q46. A 30-year-old breastfeeding mother presents 3 weeks after delivery with a painful, erythematous, hard wedge-shaped area on her right breast, accompanied by a fever of 38.5°C and chills. What is the diagnosis, and what is the instruction regarding breastfeeding? A) Breast engorgement; Discontinue breastfeeding completely B) Acute Mastitis; Continue frequent breastfeeding from both breasts, including the affected side, and start antibiotics C) Breast abscess; Incise and drain immediately in the clinic D) Galactocele; Compress tightly with ice packs

• Correct Answer: B
• Rationale: Mastitis is a localized breast tissue infection. Treatment includes antibiotics and ensuring effective milk clearance by continuing to breastfeed from both sides, which prevents progression to an abscess.

Q47. A multigravida patient develops severe primary postpartum hemorrhage immediately following delivery. The midwife notes a firm, contracted uterine fundus at the level of the umbilicus, but a steady stream of bright red vaginal blood continues to escape. What is the most likely cause of this bleeding? A) Uterine atony B) Retained placental lobule (Succenturiate lobe) C) Genital tract lacerations (Cervical or vaginal tears) D) Disseminated intravascular coagulation

• Correct Answer: C
• Rationale: Persistent, active bleeding from the vagina despite a firm, well-contracted uterus strongly points to trauma or lacerations along the birth canal.

Q48. On day 2 post-delivery, a primiparous woman appears tearful, anxious, irritable, and reports mild sleep disturbances. She states, “I feel overwhelmed and I don’t know why I am crying.” By day 7, these symptoms resolve completely without intervention. What did she experience? A) Postpartum Depression B) Postpartum Psychosis C) Postpartum Blues (“Baby Blues”) D) Generalized Anxiety Disorder

• Correct Answer: C
• Rationale: Postpartum blues affects up to 80% of new mothers, peaking around days 3–5 and resolving spontaneously within 10–14 days. It is driven by rapid hormonal shifts and fatigue, requiring reassurance rather than medication.

Q49. A midwife is conducting a predischarge education session for a postpartum woman. The midwife instructs the client that she should return to the health center immediately if she experiences which of the following danger signs? A) Increased production of yellowish-white lochia alba B) Mild abdominal cramping during breastfeeding sessions C) Sudden increase in bright red vaginal bleeding, high fever, or severe calf pain D) Profuse sweating during the first few nights at home

• Correct Answer: C
• Rationale: Secondary PPH (heavy bleeding), infection (fever), and deep vein thrombosis (severe calf pain) are critical postpartum complications that require immediate medical evaluation.

Q50. A 32-year-old G5P4 woman experiences a prolonged third stage of labor, followed by heavy bleeding. While applying controlled cord traction with strong fundal pressure, a smooth, red mass protrudes through the introitus, and the uterine fundus is no longer palpable in the abdomen. What emergency has occurred? A) Complete Uterine Prolapse B) Acute Uterine Inversion C) Cervical fibroid expulsion D) Vaginal wall hematoma rupture

• Correct Answer: B
• Rationale: Acute uterine inversion occurs when the uterine fundus turns inside out and prolapses into or through the cervix, often triggered by excessive cord traction on a fundal placenta or fundal pressure on an uncontracted uterus.