NARM NPE Practice Questions (2026) — Free Sample Questions with Answers

Answer: A

Document refusal and plan labor care: Correct. She has received full information and shows understanding, so her decision is an informed refusal. The midwife documents the discussion and her choice and plans intrapartum care accordingly (for example, risk-based assessment in labor), continuing shared decision making.

Transfer her care to a physician: Declining a screening test is not a medical complication; transfer is over-escalation and can feel punitive.

Collect the swab at the next visit anyway: Doing a procedure the client has refused violates her autonomy and consent.

Require a signed hospital-birth agreement: Making care conditional on agreeing to a different birth site is coercive, not shared decision making.

Informed refusal is respected and documented, and the midwife plans care around it rather than overriding or abandoning the client.

Answer: B

Misoprostol: Misoprostol is a uterotonic option that is not contraindicated by hypertension.

Methylergonovine: Correct. Methylergonovine causes vasoconstriction and can raise blood pressure sharply; it is contraindicated with hypertension or preeclampsia.

Oxytocin by IV infusion: Further oxytocin, such as an IV infusion, is safe with hypertension and is a usual next uterotonic step.

Tranexamic acid: Tranexamic acid is an antifibrinolytic used for hemorrhage; elevated blood pressure is not a contraindication.

Check blood pressure before giving methylergonovine; hypertension rules it out.

Answer: D

Acute cholecystitis: Cholecystitis causes right upper quadrant pain, often after fatty meals, not dysuria with CVA tenderness.

Cystitis: Cystitis causes dysuria and frequency but not fever, chills or CVA tenderness.

Kidney stone: A stone can cause flank pain and CVA tenderness but typically colicky pain without high fever and chills.

Pyelonephritis: Correct. Fever, chills and costovertebral angle tenderness with urinary symptoms indicate upper urinary tract (kidney) infection, which requires prompt medical referral in pregnancy.

CVA tenderness plus fever points to pyelonephritis, which needs prompt referral in pregnancy.

Answer: C

Continue weekly visits without testing: Under-escalation: past 41 weeks, routine care alone misses changes in fetal wellbeing.

Castor oil to start labor today: Castor oil is not a substitute for fetal surveillance, and it can cause cramping, diarrhea and dehydration.

NST and amniotic fluid assessment: Correct. Risk of stillbirth and low fluid rises after 41 weeks, so fetal surveillance with a nonstress test and amniotic fluid assessment supports informed waiting.

Re-date the pregnancy by fundal height: Fundal height is not reliable for dating late in pregnancy.

As a pregnancy goes past 41 weeks, offer fetal surveillance and discuss options with informed consent; post-term is 42 0/7 weeks or more.

Answer: A

Placenta previa: Correct. Painless bright red bleeding with a soft, nontender uterus in the third trimester is the classic picture of placenta previa; avoid digital exam and transfer.

Bloody show of labor: Bloody show is a small amount of blood-tinged mucus with cervical change in labor, not a moderate bleed without contractions.

Placental abruption: Abruption usually brings pain and a firm, tender uterus, often with dark blood.

Postcoital cervical bleeding: The stem rules out recent intercourse, and cervical bleeding is usually light spotting.

Painless bright red bleeding in late pregnancy suggests placenta previa (no digital exam); painful bleeding with a tender uterus suggests abruption.

Answer: B

Recheck her blood pressure in 4 hours: The 4-hour repeat is for confirming mild-range readings; severe-range BP should not wait.

Transfer to the hospital now: Correct. Two readings at or above 160/110 are severe-range hypertension, which needs immediate hospital care even when the client has no symptoms.

Schedule a physician consult this week: Under-escalation: severe-range BP carries a risk of stroke and eclampsia and needs care now.

Begin home BP checks twice a day: Home monitoring is far too little for severe-range hypertension.

BP ≥ 160/110 on repeat readings is severe range and calls for immediate transfer, with or without symptoms.

Answer: C

Occiput posterior vertex: A vertex presentation has the head over the inlet and the softer breech in the fundus, with FHT below the umbilicus.

Transverse lie: In a transverse lie the fundus and the inlet feel empty, with the poles in the flanks.

Breech: Correct. A hard, ballotable head in the fundus, a soft irregular presenting part and FHT heard above the umbilicus all point to a breech presentation.

Face presentation: A face presentation is still cephalic: the head is over the inlet and FHT are heard below the umbilicus.

In the first Leopold maneuver the head feels hard, round and ballotable; finding it in the fundus with FHT above the umbilicus suggests breech.

Answer: D

Uterine atony: Atony causes a soft, boggy fundus; this fundus is firm.

Retained placental fragments: The placenta is complete, and retained tissue usually leaves a uterus that will not stay firm.

Uterine inversion: Inversion produces severe pain, shock and a fundus that is absent or dimpled on palpation, not a firm fundus at the umbilicus.

Genital tract laceration: Correct. Continued bright red bleeding with a firm, well-contracted uterus and a complete placenta points to a laceration of the cervix, vagina or perineum; the midwife should inspect and control it.

Bleeding with a firm uterus is a laceration until proven otherwise; bleeding with a boggy uterus is atony.

Answer: D

A velamentous cord insertion: In velamentous insertion the cord itself inserts into the membranes and its vessels run to the placenta; the vessels do not end at a hole.

A circumvallate placenta: Circumvallate placenta shows a thick whitish ring on the fetal surface where the membranes fold back; it does not suggest retained tissue.

A battledore placenta: Battledore placenta means the cord inserts at the placental margin; it involves no membrane vessels or missing tissue.

A retained succenturiate lobe: Correct. Vessels crossing the membranes from the placental edge to a hole mean an accessory (succenturiate) lobe was attached there and has been left in the uterus; this is a cause of postpartum hemorrhage and needs prompt evaluation.

Vessels that run into the membranes and stop at a hole point to a missing succenturiate lobe and a high risk of hemorrhage.

Answer: C

Have the client push with each contraction: At 7 cm birth is not imminent; pushing drives the head onto the cord and worsens compression.

Push the cord back above the presenting part: Replacing the cord is not recommended: handling causes vasospasm, delays relief of compression and seldom succeeds.

Elevate the presenting part off the cord: Correct. Cord prolapse with bradycardia is an emergency. The immediate priority is to relieve cord compression by manually lifting the presenting part (with knee-chest or Trendelenburg positioning) and keep it elevated while emergency transport is activated.

Recheck the fetal heart rate in 5 minutes: Under-escalation: bradycardia with a palpable cord needs immediate action, not watchful waiting.

With cord prolapse, keep the presenting part off the cord by hand and position, and transfer immediately unless vaginal birth is imminent.

Answer: D

Bloody show of transition: Bloody show is a small amount of blood-tinged mucus and does not cause sudden fetal bradycardia.

Placental abruption: Abruption causes constant pain and a firm, tender uterus; her uterus is soft and pain-free between contractions.

Placenta previa: A previa bleeds painlessly as the cervix dilates, so she would have bled before reaching 6 cm, and the mother rather than the fetus is compromised first.

Vasa previa: Correct. In vasa previa, unprotected fetal vessels cross the membranes over the cervix and tear when the membranes rupture. The blood lost is fetal, so the fetal heart rate drops quickly while the mother stays stable. This is an emergency needing immediate transport.

Painless bleeding at the moment of rupture with sudden fetal bradycardia and a stable mother suggests vasa previa, an emergency requiring immediate transport.

Answer: B

Continue expectant support at home: Under-escalation. Waiting is reasonable in latent labor, but 4 hours without change in active labor with good contractions is not a normal variation.

Consult and arrange transfer: Correct. No cervical change for 4 hours in active labor with adequate contractions and ruptured membranes, after the simple causes (hydration, bladder, position) have been addressed, is an arrest of dilation. It needs consultation and transfer to a higher level of care.

Begin nipple stimulation to augment: Augmentation helps when contractions are weak. Hers are already strong and frequent, so more stimulation cannot fix an arrest and may cause tachysystole.

Let her rest and recheck in 4 hours: Another 4 hours of waiting after an active-phase arrest with all simple measures tried delays needed consultation.

Active-phase arrest despite adequate contractions, after correctable causes are addressed, means transfer.

Answer: A

Have her leave the pool and recheck: Correct. Hot water is the most likely cause, since the membranes are intact and the uterus is not tender. Leaving the pool (or cooling the water), offering fluids and rechecking her temperature and the FHT shortly afterward comes first. If the fever or tachycardia persists after cooling, consultation or transfer is needed.

Arrange immediate transfer for infection: Over-escalation as a first step. Nothing points to infection yet, and the hot water is an obvious, correctable cause that should be ruled out first.

Give acetaminophen and keep laboring: Treating the fever while she stays in 102°F water masks the problem and leaves the cause in place.

Continue and recheck in 1 hour: Under-escalation. Fetal tachycardia with a rising maternal temperature needs action now, not routine monitoring.

Keep pool water near body temperature. A rising maternal temperature or fetal tachycardia in the pool means leaving it and reassessing, and transferring if the findings persist.

Answer: A

Shallow latch: Correct. A creased, wedge-shaped ("lipstick") nipple after feeds with early cracking shows the nipple is compressed against the hard palate by a shallow latch; the remedy is positioning and a deeper latch.

Nipple thrush: Look-alike: thrush typically causes burning or shooting pain after a period of comfortable feeding, often with shiny pink nipples.

Nipple vasospasm: Look-alike: vasospasm causes blanching followed by color change and throbbing pain, not a wedge-shaped nipple.

Tongue-tie: Look-alike: tongue-tie can cause this nipple shape, but normal tongue extension and lift make it unlikely here.

A compressed, creased nipple after feeds is the hallmark of a shallow latch; correct positioning and latch before looking for other causes.

Answer: A

Endometritis: Correct. Fever, tachycardia, uterine tenderness and foul lochia on day 2–5 after prolonged labor and rupture of membranes are classic for endometritis, which needs consultation for antibiotics.

Engorgement-related fever: Look-alike: engorgement causes at most a low-grade fever with full, hard breasts; her breasts are soft.

Pyelonephritis: Look-alike: pyelonephritis causes fever with CVA tenderness and urinary symptoms, not a tender uterus and foul lochia.

Septic pelvic thrombophlebitis: Wrong stage: this is suspected when fever persists despite antibiotics for endometritis, not as the first presentation.

Postpartum fever with uterine tenderness and foul lochia is endometritis until proven otherwise; consult or refer for antibiotics.

Answer: D

Hemolytic disease of the newborn: Wrong timing: hemolytic jaundice typically appears in the first 24 hours.

Breast milk jaundice: Wrong timing: breast milk jaundice appears after the first week and can last for weeks.

Biliary atresia: Look-alike: biliary atresia causes prolonged jaundice with pale stools and dark urine; this baby has yellow stools.

Physiologic jaundice: Correct. Onset after 24 hours, peaking around days 3–5, in a well, feeding baby with normal output is typical of physiologic jaundice; the midwife continues to monitor and assess its progression.

Jaundice appearing after 24 hours in a well, feeding baby is usually physiologic; jaundice in the first 24 hours is pathologic until proven otherwise.