Midwife Licensing Examination (Эх баригчийн мэргэжлийн үйл ажиллагаа эрхлэх зөвшөөрлийн шалгалт, Mongolia)

A 24-year-old primigravida presents for her initial antenatal visit. She reports that her last normal menstrual period (LMP) began on May 14, 2026, and she has regular 28-day cycles. Using Naegele's rule, what is her estimated date of delivery (EDD)?

• AMarch 7, 2027
• BFebruary 14, 2027
• CFebruary 28, 2027
• DFebruary 21, 2027

During an abdominal examination of a woman at 36 weeks gestation, the midwife performs the first Leopold maneuver (fundal grip) and palpates a broad, soft, irregular, and non-ballotable mass in the uterine fundus. What fetal presentation does this finding indicate?

• ABreech presentation
• BShoulder presentation (transverse lie)
• CCephalic presentation
• DFace presentation

Which of the following maternal cardiovascular physiological adaptations is considered normal during an uncomplicated singleton pregnancy?

• ADecrease in resting heart rate by 10 to 15 beats per minute
• BMarked elevation in systemic vascular resistance during the second trimester
• CIncrease in cardiac output by 30% to 50% above pre-pregnancy levels
• DSignificant reduction in total plasma volume leading to hemoconcentration

A 35-year-old multigravida undergoes second-trimester quadruple serum screening at 16 weeks gestation. Which maternal serum biochemical marker pattern is most suggestive of fetal Down syndrome (Trisomy 21)?

• AElevated maternal serum alpha-fetoprotein (MSAFP) and elevated unconjugated estriol (uE3)
• BDecreased hCG, decreased inhibin A, and elevated MSAFP
• CElevated human chorionic gonadotropin (hCG) and elevated inhibin A, with decreased MSAFP…
• DNormal hCG, elevated MSAFP, and normal inhibin A

An Rh-negative, unsensitized primigravida (antibody screen negative) presents at 28 weeks gestation. Which clinical intervention is standard practice to prevent Rh(D) alloimmunization?

• APerform immediate diagnostic amniocentesis to determine fetal blood group antigens
• BWithhold anti-D immune globulin until immediately after delivery regardless of maternal a…
• CAdminister oral dexamethasone to downregulate maternal antibody response
• DAdminister 300 mcg (1,500 IU) of anti-D immune globulin intramuscularly

A 29-year-old woman undergoes a 75 g 2-hour oral glucose tolerance test (OGTT) for gestational diabetes screening at 26 weeks gestation. According to WHO criteria, which plasma glucose result confirms the diagnosis of gestational diabetes mellitus (GDM)?

• AFasting venous plasma glucose of 4.4 mmol/L
• B1-hour venous plasma glucose of 8.2 mmol/L
• C2-hour venous plasma glucose of 8.8 mmol/L
• DFasting venous plasma glucose of 4.9 mmol/L

A midwife measures the symphysis-fundal height (SFH) of a pregnant woman with an uncomplicated singleton pregnancy at 28 weeks gestation. Which measurement is within normal expected clinical limits using McDonald's rule?

• A21 cm
• B28 cm
• C34 cm
• D18 cm

A midwife teaches a nulliparous woman at 32 weeks gestation a daily 'count-to-ten' fetal movement method: resting on her side, she notes how long it takes to feel ten distinct movements. What should the midwife advise about a reassuring count?

• AFetal movements naturally cease entirely after 32 weeks due to limited intrauterine space
• BShe must feel at least 10 movements within 24 hours regardless of activity
• CAny perception of fewer than 30 movements in 1 hour warrants immediate emergency delivery
• DShe should perceive at least 10 distinct movements within a maximum of 2 hours while rest…

A cardiotocograph (CTG) non-stress test (NST) is performed on a 34-week gestation fetus. Over a 20-minute tracing, the baseline heart rate is 140 bpm with moderate variability, and there are two heart rate accelerations of 16 bpm above baseline lasting 20 seconds. How should the midwife interpret this tracing?

• ANon-reactive, requiring prolonged 40-minute acoustic stimulation
• BEquivocal, indicating impending fetal acidemia and requiring immediate cesarean delivery
• CReactive (reassuring), indicating fetal autonomic competence and adequate oxygenation
• DPathological, demonstrating severe fetal cardiac rhythm disturbance

Under WHO's initiative for the triple elimination of mother-to-child transmission, pregnant women should be tested at their first antenatal visit for which three infections?

• AToxoplasmosis, Rubella, and Cytomegalovirus
• BMeasles, Varicella-Zoster virus, and Chlamydia
• CSyphilis, Hepatitis B virus (HBsAg), and Human Immunodeficiency Virus (HIV)
• DHelicobacter pylori, Brucellosis, and Rabies

At a 12-week booking visit in a soum health center, a woman's hemoglobin is 104 g/L. Using the WHO cut-off for anemia in the first trimester of pregnancy, how should this result be interpreted?

• AAnemia, because the WHO cut-off in the first and third trimesters is a hemoglobin below 1…
• BNormal, because anemia in pregnancy is defined only below 90 g/L
• CNormal, because physiological hemodilution lowers the cut-off to 100 g/L in all trimesters
• DAnemia only if the woman is also symptomatic, as there is no numerical cut-off in pregnan…

Which physiological renal alteration occurs during a healthy pregnancy and directly affects clinical laboratory interpretations?

• A50% decrease in glomerular filtration rate (GFR) with elevation of serum creatinine
• BMarked narrowing of the maternal ureters and decreased renal plasma flow
• C50% increase in glomerular filtration rate (GFR) leading to lower baseline serum creatini…
• DPersistent reduction in urinary excretion of glucose and water-soluble vitamins

An ultrasound scan is performed at 11 weeks and 4 days of gestation. Which biometric measurement provides the most accurate estimation of gestational age during this developmental window?

• ABiparietal diameter (BPD)
• BAbdominal circumference (AC)
• CCrown-rump length (CRL)
• DFemur length (FL)

A woman planning pregnancy asks the midwife about periconceptional vitamin supplementation. What is the evidence-based recommendation for folic acid supplementation to prevent neural tube defects (NTDs)?

• AFolic acid is not recommended unless maternal serum ferritin is below 15 mcg/L
• B5 milligrams daily initiated only after ultrasound confirmation of a gestational sac
• C1,000 micrograms daily taken exclusively during the third trimester
• D400 micrograms (0.4 mg) daily starting at least 1 month prior to conception and continuin…

During abdominal palpation, the midwife places one hand over the lower abdomen just above the symphysis pubis, grasping the presenting part between the thumb and fingers. Which Leopold maneuver is being performed?

• AFirst maneuver (fundal grip)
• BSecond maneuver (lateral umbilical grip)
• CThird maneuver (Pawlik's grip)
• DFourth maneuver (pelvic grip)

A routine midstream urine culture at 14 weeks gestation reveals 100,000 (10^5) colony-forming units (CFU)/mL of Escherichia coli in a woman who reports no dysuria, urgency, or fever. What is the most appropriate management plan?

• AReassure the patient that asymptomatic bacteriuria requires no therapy in pregnancy
• BAdvise strict fluid restriction to prevent progressive bladder distension
• CPrescribe a targeted course of pregnancy-safe oral antibiotics followed by a test-of-cure…
• DPerform immediate diagnostic cystoscopy to rule out interstitial cystitis

A biophysical profile (BPP) is conducted on a 38-week fetus. Which combination of findings will result in a maximum normal score of 8/8 (on ultrasound parameters alone) or 10/10 (with non-stress test)?

• AAbsence of all gross movements with an amniotic fluid deepest vertical pocket >= 8 cm
• BReactive NST, fetal breathing 10 seconds, 1 gross movement, flaccid tone, and amniotic fl…
• CNon-reactive NST, no fetal breathing movements, 2 limb movements, and single deepest vert…
• DReactive NST, fetal breathing >= 30 seconds, >= 3 gross body movements, active tone (exte…

A woman at 35 weeks gestation suddenly develops dizziness, pallor, diaphoresis, nausea, and a blood pressure drop to 85/50 mmHg while lying flat on her back for an ultrasound examination. What is the immediate first-line midwifery intervention?

• AAdminister an immediate intravenous bolus of 50% hypertonic dextrose
• BPlace the patient in reverse Trendelenburg position with the head elevated 45 degrees
• CPosition the patient immediately into the left lateral tilt or left lateral recumbent pos…
• DAdminister intramuscular epinephrine to treat suspected anaphylaxis

Under the WHO 2016 antenatal care model, what is the recommended minimum number of antenatal contacts for a woman with an uncomplicated pregnancy?

• A4 contacts, as in the former focused antenatal care model
• B8 contacts
• C12 contacts
• DWeekly contacts from the first trimester (about 36 contacts)

A 31-year-old pregnant woman with chronic hypertension and pre-existing type 1 diabetes registers for antenatal care at 10 weeks gestation. To reduce her high risk of developing pre-eclampsia, what prophylactic pharmacological therapy should be initiated between 12 and 16 weeks gestation?

• AHigh-dose intramuscular vitamin K injections every 2 weeks
• BProphylactic intravenous magnesium sulfate infusion once monthly
• CLow-dose aspirin (75 to 150 mg daily) taken orally until 36 weeks gestation
• DOral spironolactone diuretic therapy throughout the second trimester

According to updated WHO intrapartum guidelines and standard midwifery practice, what clinical findings define the onset of the active phase of the first stage of labor?

• ARegular uterine contractions with cervical dilation starting from 2 cm
• BSpontaneous rupture of membranes accompanied by irregular uterine tightening
• CRegular painful contractions, significant cervical effacement, and progressive cervical d…
• DComplete cervical dilation of 10 cm with the urge to push

Which sequence correctly outlines the cardinal movements of the fetus during a normal vertex (cephalic) vaginal delivery?

• AEngagement -> Extension -> Descent -> Flexion -> Restitution -> Expulsion
• BDescent -> Extension -> Engagement -> External rotation -> Flexion -> Expulsion
• CFlexion -> Extension -> Internal rotation -> Engagement -> Descent -> Expulsion
• DEngagement -> Descent -> Flexion -> Internal rotation -> Extension -> Restitution and ext…

On the WHO modified partograph, how are the 'Alert line' and the 'Action line' plotted and interpreted during the active phase of labor?

• AThe Alert line represents dilation at 2 cm/hr, and the Action line is drawn 1 hour to its…
• BThe Action line starts at 10 cm and moves backward to 5 cm if labor arrests
• CThe Alert line starts at 4-5 cm dilation advancing at 1 cm/hr; the Action line is drawn p…
• DBoth lines are plotted vertically to monitor fetal heart rate decelerations exclusively

When performing a vaginal examination during labor, the midwife determines that the leading bony point of the fetal vertex has reached the level of the maternal ischial spines. What fetal station should be documented in the clinical record?

• AStation -3
• BStation -1
• CStation 0
• DStation +3

What are the three core evidence-based interventions comprising the Active Management of the Third Stage of Labor (AMTSL)?

• AIntramuscular ergometrine bolus prior to head delivery, continuous bladder drainage, and…
• BRoutine episiotomy, manual extraction of the placenta, and intravenous antibiotic prophyl…
• CEarly cord clamping within 10 seconds, vigorous fundal squeezing (Credé maneuver), and co…
• DA prophylactic uterotonic (oxytocin 10 IU IM or IV), controlled cord traction by a skille…

Which triad of clinical signs reliably indicates separation of the placenta from the uterine wall during the third stage of labor?

• ASudden maternal bradycardia, relaxation of the pelvic floor, and fetal head descent
• BShortening of the umbilical cord, maternal hypotension, and uterine softening
• CAbsence of vaginal bleeding, severe lower quadrant cramping, and cervical closure
• DLengthening of the umbilical cord, a sudden trickling gush of blood, and a rising, globul…

In an occipito-anterior (OA) presentation, which fetal cephalic landmark pivots beneath the maternal pubic symphysis allowing the fetal head to deliver by extension?

• AThe glabella (forehead)
• BThe mentum (chin)
• CThe subocciput (nape of the neck / occipital bone junction)
• DThe anterior fontanelle (bregma)

What is the primary technical objective of the midwife when performing manual perineal support (hands-on technique) during crowning and expulsion of the fetal head?

• ATo accelerate the speed of expulsion by forcefully pulling the head outward
• BTo stretch the vaginal introitus manually to at least 15 cm before delivery
• CTo control deflexion of the fetal head, slow the crowning process, and minimize perineal…
• DTo push the perineal body cephalad directly against the fetal brow

According to WHO intrapartum care recommendations (2018), within what time is the second stage of labour usually completed in a woman having her first baby?

• A30 minutes
• B1 hour
• C3 hours
• D5 hours

A woman at 40 weeks gestation in active labor experiences spontaneous rupture of membranes. The midwife inspects the fluid and observes thick, dark green 'pea-soup' meconium. What is the immediate midwifery action?

• AReassure the mother that green amniotic fluid is a normal variant and continue routine in…
• BPerform immediate aggressive amnioinfusion of 2,000 mL unheated normal saline
• CInitiate continuous electronic fetal heart rate monitoring (cardiotocography) and alert t…
• DInstruct the mother to bear down continuously regardless of contraction frequency

When assessing clinical pelvimetry during labor, the diagonal conjugate is measured manually at 12.5 cm. What is the estimated obstetric conjugate (true conjugate) of the pelvic inlet?

• A9.0 cm
• B11.0 cm
• C13.5 cm
• D15.0 cm

Which of the following clinical prerequisites must be confirmed before performing an artificial rupture of membranes (amniotomy) to prevent umbilical cord prolapse?

• AThe cervix must be 10 cm dilated with active maternal pushing
• BThe maternal bladder must be filled with at least 500 mL of sterile saline
• CThe fetal presenting part must be well engaged and closely applied to the maternal cervix
• DThe mother must be placed in a strict high Fowler sitting position

Immediately following the delivery of the fetal head and before the expulsion of the shoulders, what is the midwife's standard tactile check?

• AInsert two fingers into the rectum to assess levator ani tone
• BPalpate the maternal epigastrium to evaluate diaphragmatic excursion
• CSlide a gloved index finger gently around the fetal neck to check for the presence of a n…
• DPerform a digital exam of the neonate's oral cavity using forceful suctioning

Which of the following non-pharmacological comfort measures is strongly supported by evidence-based intrapartum guidelines to decrease labor pain and reduce surgical intervention rates?

• AStrict continuous supine bed rest from the time of admission
• BContinuous bladder catheterization with an indwelling Foley catheter
• CMandatory fasting from all oral fluids throughout the active phase
• DContinuous supportive companionship from a chosen birth partner or midwife throughout lab…

What is the evidence-based recommendation regarding the use of episiotomy during spontaneous vaginal birth?

• ARoutine mediolateral episiotomy should be performed on all primiparous women to prevent p…
• BEpisiotomy should be performed only when the cervix is 8 cm dilated
• CMidline episiotomy should be performed universally because it never involves the anal sph…
• DRoutine episiotomy is not recommended; it should be restricted to clinical indications su…

During low-risk active labor, how frequently should the midwife perform intermittent auscultation of the fetal heart rate, and when should the count be taken relative to contractions?

• AEvery 60 minutes before a contraction begins
• BOnly once upon admission and once after complete delivery of the neonate
• CContinuously for 10 seconds during the peak of every contraction
• DEvery 15 to 30 minutes in the first stage and every 5 minutes in the second stage, immedi…

What is the anatomical and clinical definition of the third stage of labor?

• AFrom onset of regular uterine contractions until 5 cm cervical dilation
• BFrom 5 cm cervical dilation until full cervical dilation
• CFrom full cervical dilation until complete delivery of the fetus
• DFrom the delivery of the baby until the complete expulsion of the placenta and fetal memb…

What contraction pattern is considered optimal and physiological during the active phase of normal labor?

• A1 to 2 contractions every 20 minutes lasting 15 seconds
• B7 to 8 contractions every 10 minutes lasting 90 seconds each
• CContinuous hypertonic uterine contraction lasting over 3 minutes without relaxation
• D3 to 4 contractions every 10 minutes, each lasting 45 to 60 seconds, with complete uterin…

During a vaginal examination, the midwife detects that the sagittal suture of the fetal skull is displaced posteriorly toward the maternal sacral promontory, with the anterior parietal bone felt prominently. What cephalic orientation is present?

• APosterior asynclitism (Litzmann's obliquity)
• BPersistent mentum posterior
• CComplete synclitism
• DAnterior asynclitism (Naegele's obliquity)

What is the primary physiological benefit of delayed umbilical cord clamping (clamping performed at 1 to 3 minutes after birth) in a healthy term newborn?

• AImmediate prevention of neonatal hyperbilirubinemia
• BImmediate closure of the infant's anterior fontanelle
• CElimination of the need for neonatal hepatitis B birth-dose vaccination
• DTransfusion of placental blood providing increased neonatal blood volume and improved iro…

A midwife assesses uterine involution in a healthy postpartum woman. What is the expected rate of fundal descent during the normal puerperium?

• AThe fundus ascends 2 cm every day until day 14
• BThe fundus descends completely into the true pelvis within 1 hour after placental expulsi…
• CThe fundus remains at the level of the umbilicus throughout the first 6 weeks
• DThe fundus descends by approximately 1 to 2 cm (one fingerbreadth) per day, becoming non-…

Which chronological sequence and clinical appearance correctly describe the normal progression of postpartum lochia?

• ALochia alba (days 1-3) -> Lochia serosa (days 4-10) -> Lochia rubra (days 10-21)
• BLochia rubra occurs exclusively for 6 weeks with continuous bright red heavy bleeding
• CLochia serosa (bright yellow, days 1-7) -> Lochia rubra (blood clots, days 8-14) -> Lochi…
• DLochia rubra (dark red, days 1-3/4) -> Lochia serosa (pinkish-brown, days 4-10) -> Lochia…

In the neuroendocrine control of lactation, which hormones are responsible for milk production (synthesis) and the milk ejection ('let-down') reflex, respectively?

• AOxytocin for milk synthesis; Prolactin for milk ejection
• BHuman placental lactogen for milk synthesis; Luteinizing hormone for milk ejection
• CEstrogen for milk synthesis; Progesterone for milk ejection
• DProlactin from the anterior pituitary for synthesis; Oxytocin from the posterior pituitar…

Which combination of clinical signs indicates an effective, asymmetrical breastfeeding latch during an infant feeding observation?

• AThe mother feels severe, persistent pinching nipple pain throughout the entire 30-minute…
• BThe infant sucks solely on the tip of the nipple with lips curled inward and audible clic…
• CThe infant's head is sharply flexed toward the sternum with rapid, shallow sucking withou…
• DThe infant's mouth is widely open, the lower lip is flanged outward, the chin rests firml…

A primiparous woman on postpartum day 12 presents with a temperature of 38.8°C, rigors, headache, and severe pain in her right breast. On examination, a well-demarcated, wedge-shaped area of erythema, induration, and intense tenderness is noted in the upper outer quadrant of the right breast. What is the diagnosis and correct clinical management?

• APhysiological breast engorgement; manage with tight breast binding and fluid restriction
• BBreast abscess; perform immediate wide incision and debridement and permanently cease lac…
• CAcute infective mastitis; continue breastfeeding/expressing from both breasts and initiat…
• DGalactocele; perform needle aspiration and administer intramuscular bromocriptine

On postpartum day 4, a woman reports feeling tearful, anxious, irritable, and overwhelmed by minor parenting concerns, despite loving her baby. Her physical exam, vital signs, and sleep during infant nap times are normal. How should the midwife distinguish postpartum blues from postpartum depression?

• APostpartum blues only occurs after 6 months of delivery and indicates long-term personali…
• BPostpartum blues requires immediate hospitalization and initiation of high-dose atypical…
• CPostpartum blues is characterized by persistent severe suicidal ideation and auditory com…
• DPostpartum blues is a transient emotional lability peaking around day 4-5 and resolving s…

A woman who underwent emergency cesarean delivery 3 days ago complains of left lower leg pain. On assessment, the midwife notes unilateral left calf swelling (circumference 3 cm greater than right), warmth, and localized tenderness. What is the immediate and safe midwifery action?

• APerform vigorous deep tissue massage on the left calf to break down suspected muscle spas…
• BAvoid calf massage, report urgently to the obstetrician, and arrange compression duplex u…
• CInstruct the woman to perform 100 deep knee squats to stimulate venous return
• DApply very hot wet compresses to the entire left leg for 12 hours