Certified Nurse Midwife Exam Questions and Answers

If you’re preparing for the CNM exam, whether you’re a new graduate, returning clinician, or simply sharpening your midwifery knowledge — this practice bank gives you clinical vignettes that mimic real exam stems. Each question is grounded in everyday midwifery practice: maternal-fetal medicine issues, obstetric emergencies, newborn management, contraception and lactation guidance, pharmacology in pregnancy and postpartum, legal and ethical dilemmas, and public-health-focused scenarios.

You’ll get:

• Realistic case stems that reflect the thinking patterns required on the CNM exam.
• Clear, actionable explanations that teach clinical reasoning.
• Topic coverage designed around tested domains so you can focus review where it matters.

What you will learn

After completing these practice questions you will be able to:

• Recognize and prioritize obstetric emergencies (uterine rupture, AFE, severe PPH).
• Apply evidence-based intrapartum management (when to augment labor, when to proceed to operative delivery).
• Manage antenatal complications (preterm labor, preeclampsia, placenta previa/accreta, fetal growth restriction) with appropriate surveillance and timing of delivery.
• Counsel and safely prescribe in pregnancy and lactation (vaccines, psychotropics, anticoagulation, antitubercular and antiretroviral therapy).
• Diagnose and initiate neonatal stabilization (hypoglycemia, RDS, HIE, NAS).
• Approach contraception and postpartum family planning pragmatically (immediate LARC, IUD timing, sterilization consent).
• Navigate ethical and legal scenarios (consent, refusal of transfusion, adolescent confidentiality).
• Interpret diagnostic pathways (when to use ultrasound vs MRI, fetal echocardiography, HSG, amniocentesis, genetic testing).
• Integrate public health best practices (GBS, HBV, HIV, TB, Zika, CMV, and immunizations).

Complete topics covered

This bank intentionally covers the breadth and depth of CNM practice. Major topics include:

• Antepartum care & maternal medicine: chronic hypertension, diabetes, thyroid disease, thrombophilias, cardiomyopathy, hepatic disease, infections (HIV, HBV, HCV, TB, CMV, Zika), genetic counseling and preconception planning.
• Intrapartum management: fetal monitoring interpretation, induction/augmentation strategies, operative vaginal delivery criteria, TOLAC/VBAC considerations, cord issues (vasa previa), shoulder dystocia algorithms.
• Obstetric emergencies: uterine rupture, amniotic fluid embolism, massive postpartum hemorrhage (balloon, embolization, hysterectomy), sepsis bundles, anaphylaxis in labor.
• Postpartum care & lactation: breastfeeding with maternal medications, mastitis/abscess management, postpartum mood disorders (psychosis), contraception choices during lactation, wound care after cesarean.
• Neonatology essentials: recognition/management of neonatal hypoglycemia, RDS, MAS, PPHN, HIE (therapeutic hypothermia), NAS, newborn screening follow-up (MCAD, congenital hypothyroidism), feeding support.
• Gynecology & reproductive health: STI management in pregnancy, cervical lesions in pregnancy, postpartum sterilization consent requirements, fertility preservation, myomectomy implications.
• Anesthesia, analgesia & perioperative care: neuraxial analgesia timing with anticoagulation, antibiotic prophylaxis dosing in obesity, airway and anesthesia planning in complex patients.
• Ethics & legal issues: informed refusal (transfusion), adolescent confidentiality, consent timing for sterilization, maternal autonomy vs fetal interests.
• Public health & prevention: immunization timing (Tdap), management of exposures (Zika, rubella), maternal antiviral prophylaxis to reduce vertical transmission.

Each question and explanation is mapped to these domains so you can target weak areas efficiently.

Sample Questions and Answers

A laboring patient with suspected chorioamnionitis has fetal tachycardia and maternal fever. Which neonatal action is anticipated at delivery?

A. No neonatal evaluation required if the baby looks well
B. Neonatal evaluation and likely empiric antibiotics and observation for sepsis, because maternal intrapartum infection increases newborn risk of early-onset sepsis
C. Immediate discharge of the newborn home with mother without assessment
D. Only give vitamin K

Correct: B
Explanation: Maternal chorioamnionitis elevates newborn sepsis risk; neonates should be evaluated, often receive empiric IV antibiotics pending cultures, and be observed closely. Decisions depend on local protocols and neonatal condition, but assuming no evaluation is unsafe.

A woman with antiphospholipid antibody (APL) positivity but no prior pregnancy loss asks about prophylaxis in pregnancy. What is evidence-based management to reduce obstetric complications?

A. APL antibodies without clinical history require no special management and no monitoring
B. For women with APL and prior pregnancy losses or obstetric complications, prophylactic low-dose aspirin plus heparin during pregnancy reduces recurrent loss risk; for APL positivity without clinical history, management is individualized — involve maternal-fetal medicine and hematology for risk stratification
C. Prescribe high-dose warfarin throughout pregnancy as prophylaxis
D. Antiphospholipid antibodies have no impact on pregnancy outcomes and require no counseling

Correct: B
Explanation: Antiphospholipid syndrome with obstetric manifestations benefits from aspirin plus heparin. Isolated antibody positivity without clinical events needs personalized assessment; indiscriminate anticoagulation is not indicated due to bleeding risk. Specialist involvement ensures appropriate prophylaxis and monitoring.

A 28-year-old G1 at 32 weeks gestation has a 1-hour glucose challenge test of 165 mg/dL (non-fasting). What is the best next step?

A. Start insulin therapy immediately
B. Obtain a 3-hour oral glucose tolerance test (OGTT)
C. Repeat 1-hour glucose challenge in 48 hours
D. Counsel on diet only and recheck at 36 weeks
Correct: B
Explanation: A 1-hour glucose screening ≥140–160 (depending on protocol) requires diagnostic testing. The standard next step is a 3-hour OGTT to confirm gestational diabetes. Immediate insulin without confirmatory testing is premature; repeating screening is less reliable. Counseling on diet is appropriate but should follow diagnostic confirmation so management is evidence-based and individualized.

A laboring patient at 39 weeks has persistent category II fetal heart tracing with recurrent variables and minimal variability despite maternal repositioning. Which is the most appropriate immediate action?

A. Prepare for emergency cesarean delivery
B. Start IV oxytocin augmentation
C. Administer oxygen to the mother and perform vaginal exam for prolapsed cord
D. Continue observation and repeat tracing in 30 minutes
Correct: C
Explanation: Recurrent variable decelerations with minimal variability require immediate evaluation for reversible causes: repositioning, oxygen, IV fluids, and vaginal exam to rule out cord prolapse. Emergency cesarean is indicated for persistent Category III or nonreassuring tracings after resuscitative measures fail. Oxytocin would worsen cord compression; observation alone risks worsening fetal compromise.

Which of the following is the most sensitive screening test for maternal iron deficiency in pregnancy?

A. Hemoglobin concentration
B. Hematocrit
C. Serum ferritin
D. Mean corpuscular volume (MCV)
Correct: C
Explanation: Serum ferritin reflects iron stores and is the most sensitive test for iron deficiency, especially in pregnancy. Hemoglobin and hematocrit indicate anemia but are late findings. MCV can suggest microcytosis but is not sensitive early. Note ferritin is an acute phase reactant and may be elevated with inflammation; clinical context matters.

For a patient with preeclampsia with severe features at 34 weeks, which is the recommended antihypertensive to start for acute severe blood pressure control?

A. Labetalol IV bolus or infusion
B. Oral nifedipine as monotherapy only if oral intake is impossible
C. Methyldopa IV bolus
D. Subcutaneous terbutaline
Correct: A
Explanation: First-line agents for acute severe hypertension in pregnancy include IV labetalol and IV hydralazine, or immediate-release oral nifedipine if IV access unavailable. Methyldopa is used for chronic management, not acute severe control. Terbutaline is a tocolytic and not indicated for blood pressure control.

A postpartum patient with heavy lochia and boggy fundus is found to have retained placental tissue suspected. Initial management should include:

A. Immediate hysterectomy
B. Manual removal of placenta under anesthesia
C. High-dose oxytocin only
D. Observation and return in 24 hours
Correct: B
Explanation: Retained placental tissue causing hemorrhage requires prompt manual removal in the operating room or birthing suite under appropriate anesthesia to control bleeding and prevent infection. Oxytocin may help uterine contraction but is insufficient if tissue is retained. Hysterectomy is a last resort when bleeding is life-threatening and conservative measures fail.

A newborn has poor tone, respiratory distress and meconium-stained fluid after an unassisted vaginal delivery. Initial step in neonatal resuscitation?

A. Suction the mouth and nose, stimulate, and assess breathing/HR
B. Intubate immediately before stimulation
C. Administer naloxone IM to the newborn
D. Begin chest compressions immediately
Correct: A
Explanation: Initial steps in neonatal resuscitation are drying, stimulating, clearing airway by suctioning (if obstruction or meconium with depressed infant), and assessing breathing and heart rate. Intubation is for persistent airway obstruction or inability to ventilate. Naloxone is indicated only if maternal opioid exposure suspected and newborn depressed. Chest compressions are started if HR <60 bpm after effective ventilation.

A pregnant patient with a history of epilepsy on valproate wishes to conceive. Best advice regarding medication?

A. Continue valproate; switch only after pregnancy confirmed
B. Switch to a safer antiepileptic preconception, such as lamotrigine, in consultation with neurology
C. Stop all antiepileptic medications prior to conception to avoid teratogenicity
D. Continue current regimen but add high-dose folic acid only after pregnancy start
Correct: B
Explanation: Valproate carries high teratogenic risk; plan preconception with neurology to switch to a lower-risk agent like lamotrigine when possible while balancing seizure control. Stopping meds abruptly risks seizures and trauma. High-dose folate (4 mg) should be started preconceptionally but is not sufficient alone if the teratogenic risk from valproate remains.

A breastfeeding mother is concerned about weight loss in her infant. At 2 weeks, weight is down 10% from birth. Which is the best immediate response?

A. Reassure that 10% is normal and no action needed
B. Evaluate feeding technique, frequency, and observe a feed; consider lactation consult
C. Recommend immediate formula supplementation for all feeds
D. Start phototherapy for possible dehydration
Correct: B
Explanation: Weight loss >7–10% at two weeks warrants evaluation. First steps: assess breastfeeding technique, frequency, latch, maternal milk supply, and observe a feeding; offer lactation support. Routine formula supplementation may be needed if inadequate intake is confirmed but should follow assessment. Phototherapy is unrelated unless hyperbilirubinemia present.

Which test is most appropriate for screening for neural tube defects in pregnancy?

A. Cell-free DNA testing (cfDNA)
B. Maternal serum alpha-fetoprotein (MSAFP) at 15–20 weeks
C. First-trimester combined screening (nuchal + PAPP-A)
D. Routine urine protein at prenatal visit
Correct: B
Explanation: Maternal serum AFP measured at 15–20 weeks is used to screen for open neural tube defects. cfDNA targets chromosomal aneuploidies, not NTDs. First-trimester combined screening assesses aneuploidy risk. Urine protein screens for preeclampsia, not neural tube defects.

A patient with confirmed gestational diabetes controlled by diet has a term vaginal delivery. What’s recommended postpartum regarding glucose testing?

A. No follow-up needed if diet controlled during pregnancy
B. 75-gram 2-hour OGTT at 6–12 weeks postpartum to screen for persistent diabetes
C. Repeat 1-hour glucose challenge in 1 year only
D. HbA1c immediately postpartum before discharge
Correct: B
Explanation: Standard recommendation is a 75-g 2-hour OGTT at 6–12 weeks postpartum to detect persistent diabetes after gestational diabetes. HbA1c immediately postpartum is unreliable due to peripartum changes. Yearly screening thereafter is needed, but immediate postpartum OGTT is essential.

In a patient with suspected placenta accreta spectrum on ultrasound, what is the most appropriate management plan?

A. Attempt manual placental removal at delivery to minimize blood loss
B. Plan delivery in a tertiary center with multidisciplinary team and likely scheduled cesarean hysterectomy
C. Proceed with vaginal delivery and observe for postpartum hemorrhage
D. Use methotrexate post-partum to treat retained placenta accreta
Correct: B
Explanation: Placenta accreta spectrum carries high hemorrhage risk; management includes planned delivery at a tertiary center with multidisciplinary team (OB surgery, anesthesia, interventional radiology, blood bank) and often scheduled cesarean hysterectomy without attempting placenta removal. Methotrexate is not standard for placenta accreta and manual removal risks catastrophic bleeding.

A patient with Rh-negative blood who is unsensitized presents after first-trimester miscarriage managed surgically. What is recommended?

A. No Rh prophylaxis needed in first trimester
B. Administer Rho(D) immune globulin (RhIG) within 72 hours of event
C. Give routine IVIG instead of RhIG
D. Only test paternal blood before deciding
Correct: B
Explanation: RhIG is recommended after pregnancy loss or procedures in Rh-negative unsensitized women to prevent alloimmunization, regardless of trimester, typically within 72 hours. IVIG is not used for this purpose. Paternal testing is not required to decide prophylaxis.

For a woman with chorioamnionitis in labor, the best intrapartum management includes:

A. Immediate cesarean delivery in all cases
B. Broad-spectrum IV antibiotics (e.g., ampicillin + gentamicin) and prompt delivery when indicated
C. Oral antibiotics and outpatient follow up
D. Delay delivery until labor progresses spontaneously despite antibiotics
Correct: B
Explanation: Chorioamnionitis requires prompt broad-spectrum IV antibiotics and expedited delivery; cesarean only when obstetrically indicated. Oral outpatient antibiotics are inappropriate. Timely delivery reduces maternal/fetal complications; delaying without indication increases risk.

Which immunization is strongly recommended during every pregnancy to protect the newborn?

A. Live attenuated influenza vaccine between 24–36 weeks
B. Tdap (tetanus, diphtheria, pertussis) between 27–36 weeks each pregnancy
C. MMR during pregnancy if non-immune
D. Varicella vaccine at 30 weeks gestation
Correct: B
Explanation: Tdap between 27–36 weeks in each pregnancy maximizes passive antibody transfer to protect the neonate from pertussis. Inactivated influenza vaccine is recommended any trimester, not live. Live vaccines (MMR, varicella) are contraindicated in pregnancy; non-immune women should be immunized postpartum.

A 29-year-old at 24 weeks has new onset hypertension and proteinuria consistent with preeclampsia without severe features. What counseling is appropriate regarding timing of delivery?

A. Immediate delivery regardless of gestational age
B. Expectant management with close monitoring until at least 37 weeks unless condition worsens
C. Elective termination of pregnancy is required
D. Allow home management and routine prenatal visits only
Correct: B
Explanation: For preeclampsia without severe features at 24 weeks, expectant management in a facility with close maternal and fetal surveillance is reasonable to prolong pregnancy toward fetal maturity, with delivery indicated at term or earlier if severe features develop. Immediate delivery at 24 weeks is usually not indicated unless maternal/fetal status demands it.

A woman with suspected vulvovaginal candidiasis will likely have which combination on exam and testing?

A. Copious frothy yellow discharge; positive pH >5; motile trichomonads on wet prep
B. Thick white curdlike discharge; normal vaginal pH (≤4.5); pseudohyphae on KOH prep
C. Thin watery discharge; positive clue cells on wet mount; pH >4.5
D. Foul smelling discharge; positive test for bacterial growth only
Correct: B
Explanation: Candidiasis typically presents with thick, white, curdlike discharge, normal/acidic vaginal pH ≤4.5, and pseudohyphae on KOH prep. Trichomonas yields frothy yellow/green discharge and elevated pH; bacterial vaginosis shows thin discharge and clue cells. Accurate diagnosis guides targeted therapy.

Which of the following is the best method to reduce perinatal transmission of hepatitis B from an HBsAg-positive mother?

A. Start maternal antiviral therapy in first trimester regardless of viral load
B. Give the newborn hepatitis B immune globulin (HBIG) and hepatitis B vaccine within 12 hours of birth
C. Isolate the newborn and delay breastfeeding for 6 months
D. Cesarean delivery is required to prevent transmission
Correct: B
Explanation: Neonatal HBIG plus the first dose of hepatitis B vaccine within 12 hours of birth is highly effective at preventing perinatal transmission. Maternal antivirals are indicated when HBV DNA is very high typically in third trimester. Breastfeeding is allowed after immunoprophylaxis. Cesarean is not routinely recommended solely for HBV.

A patient in active labor has arrest of descent in the second stage despite adequate maternal effort and fetal station high in pelvis. Fetal heart rate is category I. Which is the next best step?

A. Proceed with forceps or vacuum assisted delivery if criteria met and maternal/fetal conditions favorable
B. Immediate cesarean without attempting assisted vaginal delivery
C. Prolong pushing indefinitely until descent occurs
D. Give high-dose oxytocin to increase uterine contractions
Correct: A
Explanation: If maternal and fetal conditions are appropriate and there is arrest of descent in second stage, operative vaginal delivery (forceps or vacuum) may be indicated when criteria met, especially with a favorable pelvis, fetal position, and maternal effort. Cesarean may be needed if assisted delivery contraindicated or fails. Oxytocin won’t resolve mechanical arrest.

Which screening test has the highest sensitivity for detecting group B Streptococcus (GBS) colonization in pregnant women at 35–37 weeks?

A. Urine culture for GBS during pregnancy
B. Rectovaginal culture at 35–37 weeks
C. Rapid intrapartum PCR only if membranes rupture
D. Maternal blood serology for GBS antibodies
Correct: B
Explanation: Routine rectovaginal culture at 35–37 weeks gestation is the standard screening method with high sensitivity for GBS colonization. Urine culture indicates heavy colonization when positive but is not standard screening. Intrapartum PCR can be useful but is not universally used as primary screen. Serology has no role.

A patient on methadone maintenance is pregnant. Which counseling point is correct?

A. Methadone should be stopped during pregnancy to prevent neonatal withdrawal
B. Continue methadone; opioid agonist therapy reduces maternal risks and improves outcomes
C. Switch to buprenorphine without specialist input immediately upon pregnancy confirmation
D. Encourage abrupt tapering in third trimester to avoid NAS (neonatal abstinence syndrome)
Correct: B
Explanation: Maintenance opioid agonist therapy (methadone or buprenorphine) should be continued during pregnancy; abrupt cessation risks relapse, overdose, and poor outcomes. Transition between therapies requires specialist input and should be individualized. NAS may occur but is managed postnatally; maternal stability is prioritized.

A 30-year-old with a known mechanical heart valve is pregnant and requires anticoagulation. Which approach balances maternal thromboembolism risk and fetal safety?

A. Continue warfarin throughout pregnancy because it’s best for maternal valve thrombosis prevention
B. Use low-molecular-weight heparin (LMWH) with anti-Xa monitoring during first trimester, consider warfarin in second trimester if necessary, and switch to LMWH near delivery — individualized and multidisciplinary approach required
C. Stop all anticoagulation during pregnancy to avoid teratogenicity
D. Use aspirin monotherapy only
Correct: B
Explanation: Anticoagulation in pregnant patients with mechanical valves is complex: LMWH with anti-Xa monitoring or adjusted-dose UFH can be used; warfarin is teratogenic in first trimester but provides superior thrombosis prevention. Many teams individualize strategy, sometimes using LMWH in first trimester, warfarin in second, and LMWH near delivery. Multidisciplinary care is essential.

Which intervention best reduces postpartum endometritis risk after cesarean delivery?

A. Routine pelvic packing after closure
B. Single preoperative prophylactic IV antibiotic dose before incision
C. Postoperative oral antibiotics for 7 days to all cesarean patients
D. Delayed cord clamping for 5 minutes
Correct: B
Explanation: A single prophylactic IV antibiotic given prior to skin incision (commonly cefazolin) significantly reduces postpartum endometritis after cesarean. Routine prolonged postoperative antibiotics are not recommended for all. Pelvic packing or delayed cord clamping do not reduce endometritis risk.

A patient with hyperemesis gravidarum is hospitalized with 10% weight loss, ketonuria, and inability to tolerate oral intake. Best initial treatment includes:

A. Intravenous fluids, electrolyte correction, antiemetics (e.g., ondansetron), and nutritional support as needed
B. Immediate nasogastric feeding without antiemetics
C. Discharge home with dietary advice only
D. Start high-dose corticosteroids to reduce vomiting
Correct: A
Explanation: Management of hyperemesis gravidarum includes IV fluids to correct dehydration and electrolytes, antiemetics, thiamine before glucose if malnourished, and nutritional support (enteral or parenteral) if needed. NG feeding may be used if oral intake fails but should follow stabilization. Steroids are not first-line.

A 22-year-old has a suspected ectopic pregnancy: positive pregnancy test, lower abdominal pain, and empty uterus on transvaginal ultrasound with beta-hCG of 1600 mIU/mL. Next best step?

A. Immediate laparoscopy without further testing
B. Repeat quantitative beta-hCG in 48 hours and repeat transvaginal ultrasound; consider methotrexate if levels rise appropriately and patient stable
C. Start expectant management and advise return only if pain worsens
D. Administer single-dose antibiotics for presumed PID
Correct: B
Explanation: With an indeterminate transvaginal ultrasound and low beta-hCG near discriminatory zone (~1500–2000), the appropriate approach is serial quantitative beta-hCG testing in 48 hours and repeat ultrasound. If hCG rises abnormally or ectopic confirmed and patient stable, methotrexate may be used based on criteria. Immediate surgery is reserved for instability or rupture.

A breastfeeding mother with active tuberculosis has been on effective anti-TB therapy for 2 weeks and is clinically improving. What is the current recommendation regarding breastfeeding and infant prophylaxis?

A. She must never breastfeed while on TB therapy
B. After 2 weeks of effective therapy and clinical improvement, most guidelines allow breastfeeding to continue; the infant should be evaluated and may receive isoniazid prophylaxis and follow-up per public health guidance — coordinate with infectious disease and pediatrics
C. Stop maternal therapy to allow safe breastfeeding
D. Immediate separation of mother and infant for 6 months despite maternal improvement

Correct: B
Explanation: When maternal TB is treated effectively and the mother is clinically improving (after appropriate initial therapy and deemed noninfectious), breastfeeding may continue because anti-TB drugs in milk are not a contraindication, and benefits outweigh risks. Infant evaluation and prophylaxis per public health protocols are necessary to prevent disease. Blanket separation or stopping therapy is unwarranted.