Gyneco final

A 20-year-old female presents to your office for routine well-woman examination. She has a history of acne, for which she takes minocycline and isotretinoin on a daily basis. She also has a history of epilepsy that is well controlled on valproic acid. She also takes a combined oral contracep- tive birth control pill containing norethindrone acetate and ethinyl estra- diol. She is a nonsmoker but drinks alcohol on a daily basis. She is concerned about the effectiveness of her birth control pill, given all the medications that she takes. She is particularly worried about the effects of her medications on a developing fetus in the event of an unintended preg- nancy. Which of the following drugs has the lowest potential to cause birth defects?

A patient presents for prenatal care in the second trimester. She was born outside the United States and has never had any routine vaccinations. Which of the following vaccines is contraindicated in pregnancy?

Your 25-year-old patient is pregnant at 36 weeks gestation. She has an acute urinary tract infection (UTI). Which of the following medications is contraindicated in the treatment of the UTI in this patient?

You diagnose a 21-year-old woman at 12 weeks gestation with gonorrhea cervicitis. Which of the following is the most appropriate treatment for her infection?

A 36-year-old G0 who has been epileptic for many years is contem- plating pregnancy. She wants to go off her phenytoin because she is con- cerned about the adverse effects that this medication may have on her unborn fetus. She has not had a seizure in the past 5 years. Which of the following is the most appropriate statement to make to the patient?

At 1 year of age, a child has six deciduous teeth, which are discolored and have hypoplasia of the enamel. Match the appropriate scenario with the antibiotic most likely responsible for the clinical findings presented.

During routine auditory testing of a 2-day-old baby, the baby failed to respond to high-pitched tones. Match the appropriate scenario with the antibiotic most likely responsible for the clinical findings presented.

A 24-year-old primigravida with twins presents for routine ultra- sonography at 20 weeks gestation. Based on the ultrasound findings, the patient is diagnosed with dizygotic twins. Which of the following is true regarding the membranes and placentas of dizygotic twins?

After delivery of a term infant with Apgar scores of 2 at 1 minute and 7 at 5 minutes, you ask that umbilical cord blood be collected for pH. The umbilical arteries carry which of the following?

During the routine examination of the umbilical cord and placenta after a spontaneous vaginal delivery, you notice that the baby had only one umbilical artery. Which of the following is true regarding the finding of a single umbilical artery?

A 22-year-old G1P0 at 28 weeks gestation by LMP presents to labor and delivery complaining of decreased fetal movement. She has had no pre- natal care. On the fetal monitor there are no contractions. The fetal heart rate is 150 beats per minute and reactive. There are no decelerations in the fetal heart tracing. An ultrasound is performed in the radiology department and shows a 28-week fetus with normal-appearing anatomy and size con- sistent with dates. The placenta is implanted on the posterior uterine wall and its margin is well away from the cervix. A succenturiate lobe of the pla- centa is seen implanted low on the anterior wall of the uterus. Doppler flow studies indicate a blood vessel is traversing the cervix connecting the two lobes. This patient is most at risk for which of the following?

Healthy 34-year-old G1P0 patient comes to see you in your office for a routine OB visit at 12 weeks gestational age. She tells you that she has stopped taking her prenatal vitamins with iron supplements because they make her sick and she has trouble remembering to take a pill every day. A review of her prenatal labs reveals that her hematocrit is 39%. Which of the following statements is the best way to counsel this patient?

A pregnant patient of yours goes to the emergency room at 20 weeks gestational age with complaints of hematuria and back pain. The emer- gency room physician orders an intravenous pyelogram (IVP) as part of a workup for a possible kidney stone. The radiologist indicates the absence of nephrolithiasis but reports the presence of bilateral hydronephrosis and hydroureter, which is greater on the right side than on the left. Which of the following statements is true regarding this IVP finding?

During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks gestational age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other parameters of the urine test are normal. Which of the following is the most likely etiology of the increased sugar detected in the urine?

A 33-year-old G2P1 is undergoing an elective repeat cesarean section at term. The infant is delivered without any difficulties, but the placenta cannot be removed easily because a clear plane between the placenta and uterine wall cannot be identified. The placenta is removed in pieces. This is followed by uterine atony and hemorrhage. Match the descriptions with the appropriate placenta type.

The shortest distance between the sacral promontory and the symphysis pubis is called which of the following?

A patient presents in labor at term. Clinical pelvimetry is performed. She has an oval-shaped pelvis with the anteroposterior diameter at the pelvic inlet greater than the transverse diameter. The baby is occiput posterior. The patient most likely has what kind of pelvis?

On pelvic examination of a patient in labor at 34 weeks, the patient is noted to be 6 cm dilated, completely effaced with the fetal nose and mouth palpable. The chin is pointing toward the maternal left hip. This is an example of which of the following?

A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time?

A patient presents for her first initial OB visit after performing a home pregnancy test and gives a last menstrual period of about 8 weeks ago. She says she is not entirely sure of her dates, however, because she has a long history of irregular menses. Which of the following is the most accurate way of dating the pregnancy?

A healthy 31-year-old G3P2002 patient presents to the obstetrician’s office at 34 weeks gestational age for a routine return visit. She has had an uneventful pregnancy to date. Her baseline blood pressures were 100 to 110/60 to70, and she has gained a total of 20 lb so far. During the visit, the patient complains of bilateral pedal edema that sometimes causes her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75. She denies any other symptoms or complaints. On physical examination, there is pitting edema of both legs without any calf tenderness. Which of the following is the most appropriate response to the patient’s concern?

A 28-year-old G1P0 presents to your office at 18 weeks gestational age for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occurring with movement and exercise. She denies any change in urinary or bowel habits. She also denies any fever or chills. The application of a heating pad helps alleviate the discomfort. As her obstetrician, what should you tell this patient is the most likely etiology of this pain?

A 19-year-old G1P0 presents to her obstetrician’s office for a routine OB visit at 32 weeks gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompli- ant with diet and insulin therapy. She has had two prior normal ultra- sounds at 20 and 28 weeks gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm. Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age?

A 30-year-old G2P1001 patient comes to see you in the office at 37 weeks gestational age for her routine OB visit. Her first pregnancy resulted in a vagi- nal delivery of a 9-lb 8-oz baby boy after 30 minutes of pushing. On doing Leopold maneuvers during this office visit, you determine that the fetus is breech. Vaginal examination demonstrates that the cervix is 50% effaced and 1 to 2 cm dilated. The presenting breech is high out of the pelvis. The esti- mated fetal weight is about 7 lb. The patient denies having any contractions. You send the patient for a sonogram, which confirms a fetus with a double footling breech presentation. There is a normal amount of amniotic fluid present and the head is hyperextended in the “stargazer” position. Which of the following is the best next step in the management of this patient?

A 29-year-old G1P0 presents to the obstetrician’s office at 41 weeks gestation. On physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in position. The vertex is presenting at –3 station. Which of the following is the best next step in the management of this patient?

Your patient had an ultrasound examination today at 39 weeks gestation for size less than dates.The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5 centimeters. The patient’s cervix is unfavorable. Which of the following is the best next step in the management of this patient?

An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient’s estimated date of delivery?

A new patient presents to your office for her first prenatal visit. By her last menstrual period she is 11 weeks pregnant. This is the first pregnancy for this 36-year-old woman. She has no medical problems. At this visit you observe that her uterus is palpable midway between the pubic symphysis and the umbilicus. No fetal heart tones are audible with the Doppler stethoscope. Which of the following is the best next step in the manage- ment of this patient?

A 16-year-old primigravida presents to your office at 35 weeks gesta- tion. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine. She has significant swelling of her face and extremities. She denies having contractions. Her cervix is closed and unef- faced. The baby is breech by bedside ultrasonography. She says the baby’s movements have decreased in the past 24 hours. Which of the following is the best next step in the management of this patient?

A 29-year-old G3P2 presents to the emergency center with com- plaints of abdominal discomfort for 2 weeks. Her vital signs are: blood pressure 120/70 mm Hg, pulse 90 beats per minute, temperature 36.94°C, respiratory rate 18 breaths per minute. A pregnancy test is positive and an ultrasound of the abdomen and pelvis reveals a viable 16-week gestation located behind a normal-appearing 10 × 6 × 5.5 cm uterus. Both ovaries appear normal. No free fluid is noted. Which of the following is the most likely cause of these findings?

A 32-year-old G2P1 at 28 weeks gestation presents to labor and delivery with the complaint of vaginal bleeding. Her vital signs are: blood pressure 115/67 mm Hg, pulse 87 beats per minute, temperature 37.0°C, respiratory rate 18 breaths per minute. She denies any contraction and states that the baby is moving normally. On ultrasound the placenta is anteriorly located and completely covers the internal cervical os. Which of the following would most increase her risk for hysterectomy?

A patient at 17 weeks gestation is diagnosed as having an intrauter- ine fetal demise. She returns to your office 5 weeks later and her vital signs are: blood pressure 110/72 mm Hg, pulse 93 beats per minute, tempera- ture 36.38°C, respiratory rate 16 breaths per minute. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on examination. This patient is at increased risk for which of the following?

A 24-year-old presents at 30 weeks with a fundal height of 50 cm. Which of the following statements concerning polyhydramnios is true?

A 20-year-old G1 at 32 weeks presents for her routine obstetric (OB) visit. She has no medical problems. She is noted to have a blood pressure of 150/96 mm Hg, and her urine dip shows 1+ protein. She complains of a constant headache and vision changes that are not relieved with rest or a pain reliever. The patient is sent to the hospital for further management. At the hospital, her blood pressure is 158/98 mm Hg and she is noted to have tonic-clonic seizure. Which of the following is indicated in the manage- ment of this patient?

A 32-year-old G5P1 presents for her first prenatal visit. A complete obstetrical, gynecological, and medical history and physical examination is done. Which of the following would be an indication for elective cerclage placement?

Uterine bleeding at 12 weeks gestation accompanied by cervical dilation without passage of tissue. Match above description with the correct type of abortion.

Passage of some but not all placental tissue through the cervix at 9 weeks gestation. Match above description with the correct type of abortion.

Fetal death at 15 weeks gestation without expulsion of any fetal or maternal tissue for at least 8 weeks. Match above description with the correct type of abortion.

Uterine bleeding at 7 weeks gestation without any cervical dilation. Match above description with the correct type of abortion.

Expulsion of all fetal and placental tissue from the uterine cavity at 10 weeks gestation. Match above description with the correct type of abortion.

A 20-year-old G1P0 presents to your clinic for follow-up for a suc- tion dilation and curettage for an incomplete abortion. She is asymptomatic without any vaginal bleeding, fever, or chills. Her examination is normal. The pathology report reveals trophoblastic proliferation and hydropic degenera- tion with the absence of vasculature; no fetal tissue is identified. A chest x-ray is negative for any evidence of metastatic disease. Which of the following is the best next step in her management?

A 22-year-old G1P0 presents to your clinic for follow-up of evacuation of a complete hydatidiform mole. She is asymptomatic and her examination is normal. Which of the following would be an indication to start single-agent chemotherapy?

A 32-year-old female presents to the emergency department with abdominal pain and vaginal bleeding. Her last menstrual period was 8 weeks ago and her pregnancy test is positive. On examination she is tachycardic and hypotensive and her abdominal examination findings reveal peritoneal signs, a bedside abdominal ultrasound shows free fluid within the abdominal cavity. The decision is made to take the patient to the operating room for emergency exploratory laparotomy. Which of the following is the most likely diagnosis?

A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy?

A 34-year-old G2P1 at 31 weeks gestation presents to labor and delivery with complaints of vaginal bleeding earlier in the day that resolved on its own. She denies any leakage of fluid or uterine contractions. She reports good fetal movement. In her last pregnancy, she had a low trans- verse cesarean delivery for breech presentation at term. She denies any medical problems. Her vital signs are normal and electronic external monitoring reveals a reactive fetal heart rate tracing and no uterine contractions. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa presents to the hospital with vaginal bleeding. On assessment, she has normal vital signs and the fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. No uterine contractions are demonstrated on external tocometer. Heavy vaginal bleeding is noted. Which of the following is the best next step in the management of this patient?

A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had a normal vaginal delivery at 40 weeks and the baby weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a non- smoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100 to 120/60 to 70. During her examination, you note that her fundal height measures only 25 cm. Which of the following is a likely explanation for this patient’s decreased fundal height?

A 26-year-old G1 at 37 weeks presents to the hospital in active labor. She has no medical problems and has a normal prenatal course except for fetal growth restriction. She undergoes an uncomplicated vaginal delivery of a female infant weighing 1950 g. The infant is at risk for which of the following complications?

A 39-year-old G1P0 at 39 weeks gestational age is sent to labor and delivery from her obstetrician’s office because of a blood pressure reading of 150/100 mm Hg obtained during a routine OB visit. Her baseline blood pressures during the pregnancy were 100 to 120/60 to 70. On arrival to labor and delivery, the patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. The heart rate strip is reactive and the toco- dynamometer indicates irregular uterine contractions. The patient’s cervix is 3 cm dilated. Her repeat blood pressure is 160/90 mm Hg. Hematocrit is 34.0, platelets are 160,000, SGOT is 22, SGPT is 15, and urinalysis is neg- ative for protein. Which of the following is the most likely diagnosis?

A 20-year-old G1 at 36 weeks is being monitored for preeclampsia; she rings the bell for the nurse because she is developing a headache and feels funny. As you and the nurse enter the room, you witness the patient undergoing a tonic-clonic seizure. You secure the patient’s airway, and within a few minutes the seizure is over. The patient’s blood pressure monitor indicates a pressure of 160/110 mm Hg. Which of the following medications is recommended for the prevention of a recurrent eclamptic seizure?

A 22-year-old G1 at 14 weeks gestation presents to your office with a history of recent exposure to her 3-year-old nephew who had a rubella viral infection. In which time period does maternal infection with rubella virus carry the greatest risk for congenital rubella syndrome in the fetus?

A 30-year-old class D diabetic is concerned about pregnancy. She can be assured that which of the following risks is the same for her as for the general population?

A 23-year-old G1P0 reports to your office for a routine OB visit at 28 weeks gestational age. Labs drawn at her prenatal visit 2 weeks ago reveal a 1-hour glucose test of 128, hemoglobin of 10.8, and a platelet count of 80,000. All her other labs were within normal limits. During the present visit, the patient has a blood pressure of 120/70 mm Hg. Her urine dip is negative for protein, glucose, and blood. The patient denies any com- plaints. The only medication she is currently taking is a prenatal vitamin. She does report a history of epistaxis on occasion, but no other bleeding. Which of the following medical treatments should you recommend to treat the thrombocytopenia?

A 20-year-old G1 at 38 weeks gestation presents with regular painful contractions every 3 to 4 minutes lasting 60 seconds. On pelvic examina- tion, she is 3 cm dilated and 90% effaced; an amniotomy is performed and clear fluid is noted. The patient receives epidural analgesia for pain man- agement. The fetal heart rate tracing is reactive. One hour later on repeat examination, her cervix is 5 cm dilated and 100% effaced. Which of the following is the best next step in her management?

A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. The patient noted clear fluid at the time. On examination, her cervix is 4 cm dilated and completely effaced. The fetal head is at 0 station and the fetal heart rate tracing is reactive. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Early decelerations are noted on the fetal heart rate tracing. Which of the following is the best next step in her labor management?

A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated; spontaneous rupture of membranes occurred prior to admission. She has had one prior uncomplicated vaginal delivery and denies any medical problems or past surgery. She reports an allergy to sulfa drugs. Currently, her vital signs are normal and the fetal heart rate tracing is reactive. Her prenatal record indicates that her Group B streptococcus (GBS) culture at 36 weeks was positive. What is the recommended antibiotic for prophylaxis during labor?

A 23-year-old G1 at 38 weeks gestation presents in active labor at 6 cm dilated with ruptured membranes. On cervical examination the fetal nose, eyes, and lips can be palpated. The fetal heart rate tracing is 140 beats per minute with accelerations and no (oxytocin) decelerations. The patient’s pelvis is adequate. Which of the following is the most appropriate management for this patient?

A 32-year-old G3P2 at 39 weeks gestation presented to the hospital with ruptured membranes and 4 cm dilated. She has a history of two prior vaginal deliveries, with her largest child weighing 3800 g at birth. Over the next 2 hours she progresses to 7 cm dilated. Two hours later, she remains 7 cm dilated. The estimated fetal weight by ultrasound is 3200 g. Which of the following labor abnormalities best describes this patient?

You are following a 38-year-old G2P1 at 39 weeks in labor. She has had one prior vaginal delivery of a 3800-g infant. One week ago, the esti- mated fetal weight was 3200 g by ultrasound. Over the past 3 hours her cervical examination remains unchanged at 6 cm. Fetal heart rate tracing is reactive. An intrauterine pressure catheter (IUPC) reveals two contractions in 10 minutes with amplitude of 40 mm Hg each. Which of the following is the best management for this patient?

A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, which of the following is an advantage of mediolateral episiotomy?

A 27-year-old woman (G3P2) comes to the delivery floor at 37 weeks gestation. She has had no prenatal care. She complains that, on bending down to pick up her 2-year-old child, she experienced sudden, severe back pain that now has persisted for 2 hours. Approximately 30 minutes ago she noted bright red blood coming from her vagina. By the time she arrives at the delivery floor, she is contracting strongly every 3 minutes; the uterus is quite firm even between contractions. By abdominal palpation, the fetus is vertex with the head deeply engaged. Fetal heart rate is 130 beats per minutes. The fundus is 38 cm above the symphysis. Blood for clotting is drawn, and a clot forms in 4 minutes. Clotting studies are sent to the laboratory. Which of the following actions can most likely wait until the patient is stabilized?

A 24-year-old primigravid woman, at term, has been in labor for 16 hours and has been dilated to 9 cm for 3 hours. The fetal vertex is in the right occiput posterior position, at +1 station, and molded. There have been mild late decelerations for the past 30 minutes. Twenty minutes ago, the fetal scalp pH was 7.27; it is now 7.20. For above clinical description, select the most appropriate procedure.

You have just delivered an infant weighing 2.5 kg (5.5 lb) at 39 weeks gestation. Because the uterus still feels large, you do a vaginal examination. A second set of membranes is bulging through a fully dilated cervix, and you feel a small part presenting in the sac. A fetal heart is auscultated at 60 beats per minute. For above clinical description, select the most appropriate procedure.

A 24-year-old woman (G3P2) is at 40 weeks gestation. The fetus is in the transverse lie presentation. For above clinical description, select the most appropriate procedure.

A nulliparous woman is in active labor (cervical dilation 5 cm with complete effacement, vertex at 0 station); the labor curve shows pro- tracted progression without descent following the administration of an epidural block. An IUPC shows contractions every 4 to 5 minutes, peaking at 40 mm Hg. Select the most appropriate treatment for above clinical situation.

A nulliparous woman has had arrest of descent for the past 2 hours and arrest of dilation for the past 3 hours. The cervix is dilated to 7 cm and the vertex is at +1 station. Monitoring shows a normal pattern and adequate contractions. Fetal weight is estimated at 7.5 lb. Select the most appropriate treatment for above clinical situation.

Appears to lengthen the second stage of labor. Match above description with the most appropriate type of obstetric anesthesia.

A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 2 to 10 minutes. The nurse states that the con- tractions are mild to palpation. On examination the cervix is 2 cm dilated, 50% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing isn140 beats per minute with accelerations and no decelerations. Which of the following stages of labor is this patient in?

A 28-year-old G1 at 38 weeks had a normal progression of her labor. She has an epidural and has been pushing for 2 hours. The fetal head is direct occiput anterior at +3 station. The fetal heart rate tracing is 150 beats per minute with variable decelerations. With the patient’s last push the fetal heart rate had a prolonged deceleration to the 80s for 3 minutes. You recommend forceps to assist the delivery owing to the nonreassuring fetal heart rate tracing. Compared to the use of the vacuum extractor, forceps are associated with an increased risk of which of the following neonatal complications?

You performed a forceps-assisted vaginal delivery on a 20-year-old G1 at 40 weeks for maternal exhaustion. The patient had pushed for 3 hours with an epidural for pain management. A second-degree episiotomy was cut to facilitate delivery. Eight hours after delivery, you are called to see the patient because she is unable to void and complains of severe pain. On examination you note a large fluctuant purple mass inside the vagina. What is the best management for this patient?

A 20-year-old G1 at 41 weeks has been pushing for 21/2 hours. The fetal head is at the introitus and beginning to crown. It is necessary to cut an episiotomy. The tear extends through the sphincter of the rectum, but the rectal mucosa is intact. How should you classify this type of episiotomy?

A 25-year-old G1P0 patient at 41 weeks presents to labor and delivery complaining of gross rupture of membranes and painful uterine contractions every 2 to 3 minutes. On digital examination, her cervix is 3 cm dilated and completely effaced with fetal feet palpable through the cervix. The estimated weight of the fetus is about 6 lb, and the fetal heart rate tracing is reactive. Which of the following is the best method to achieve delivery?

A 25-year-old G1 at 37 weeks presents to labor and delivery with gross rupture of membranes. The fluid is noted to be clear and the patient is noted to have regular painful contractions every 2 to 3 minutes lasting for 60 seconds each. The fetal heart rate tracing is reactive. On cervical examination she is noted to be 4 cm dilated, 90% effaced with the presenting part a −3 station. The presenting part is soft and felt to be the fetal buttock. A quick bedside ultrasound reveals a breech presentation with both hips flexed and knees extended. What type of breech presentation is described?

On postoperative day 3 after an uncomplicated repeat cesarean delivery, the patient develops a fever of 38.2°C (100.8°F). She has no com- plaints except for some fullness in her breasts. On examination she appears in no distress; lung and cardiac examinations are normal. Her breast exam- ination reveals full, firm breasts bilaterally slightly tender with no erythema or masses. She is not breast-feeding. The abdomen is soft with firm, non- tender fundus at the umbilicus. The lochia appears normal and is non- odorous. Urinalysis and white blood cell count are normal. Which of the following is a characteristic of the cause of her puerperal fever?

A 38-year-old G3P3 begins to breast-feed her 5-day-old infant. The baby latches on appropriately and begins to suckle. In the mother, which of the following is a response to suckling?

A 24-year-old G1P1 presents for her routine postpartum visit 6 weeks after an uncomplicated vaginal delivery. She states that she is having prob- lems sleeping and is feeling depressed over the past 2 to 3 weeks. She reveals that she cries on most days and feels anxious about taking care of her newborn son. She denies any weight loss or gain, but states she doesn’t feel like eating or doing any of her normal activities. She denies suicidal or homicidal ideation. Which of the following is true regarding this patient’s condition?

A 21-year-old G1 at 40 weeks, who underwent induction of labor for severe preeclampsia, delivered a 3900-g male infant via vaginal delivery after pushing for 21/2 hours. A second-degree midline laceration and side- wall laceration were repaired in the usual fashion under local analgesia. The estimated blood loss was 450 cc. Magnesium sulfate is continued post- partum for the seizure prophylaxis. Six hours after the delivery, the patient has difficulty voiding. Which is the most likely cause of her problem?

A 32-year-old G2P2 develops fever and uterine tenderness 2 days after cesarean delivery for nonreassuring fetal heart tones. She is placed on intravenous penicillin and gentamicin for her infection. After 48 hours of antibiotics she remains febrile, and on examination she continues to have uterine tenderness. Which of the following bacteria is resistant to these antibiotics and is most likely to be responsible for this woman’s infection?

A 21-year-old G2P2 calls her physician 7 days postpartum because she is concerned that she is still bleeding from the vagina. She describes the bleeding as light pink to bright red and less heavy than the first few days postdelivery. She denies fever or any cramping pain. On examination she is afebrile and has an appropriately sized, nontender uterus. The vagina con- tains about 10 cc of old, dark blood. The cervix is closed. Which of the fol- lowing is the most appropriate treatment?

A 28-year-old G2P2 presents to the hospital 2 weeks after vaginal delivery with the complaint of heavy vaginal bleeding that soaks a sanitary napkin every hour. Her pulse is 89 beats per minute, blood pressure 120/76 mm Hg, and temperature 37.1°C (98.9°F). Her abdomen is non- tender and her fundus is located above the symphysis pubis. On pelvic examination, her vagina contained small blood clots and no active bleeding is noted from the cervix. Her uterus is about 12 to 14 weeks size and non- tender. Her cervix is closed. An ultrasound reveals an 8-mm endometrial stripe. Her hemoglobin is 10.9, unchanged from the one at her vaginal delivery. β-hCG is negative. Which of the following potential treatments would be contraindicated?

A 22-year-old G1P0 has just undergone a spontaneous vaginal delivery. As the placenta is being delivered, a red fleshy mass is noted to be protruding out from behind the placenta. Which of the following is the best next step in management of this patient?

Following a vaginal delivery, a woman develops a fever, lower abdom- inal pain, and uterine tenderness. She is alert, and her blood pressure and urine output are good. Large gram-positive rods suggestive of clostridia are seen in a smear of the cervix. Which of the following is most closely tied to a decision to proceed with hysterectomy?

Three days ago you delivered a 40-year-old G1P1 by cesarean section following arrest of descent after 2 hours of pushing. Labor was also signif- icant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse pages you to come to see the patient on the postpartum floor because she has a fever of 38.8°C (102°F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breast-feed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and ten- der bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted. Her pelvic examination reveals uterine tenderness but no masses. Which of the following is the most likely diagnosis?

You are doing postpartum rounds on a 23-year-old G1P1 who is postpartum day 2 after an uncomplicated vaginal delivery. As you walk in the room, you note that she is crying. She states she can’t seem to help it. She denies feeling sad or anxious. She has not been sleeping well because of getting up every 2 to 3 hours to breast-feed her new baby. Her past medical history is unremarkable. Which of the following is the most appropriate treatment recommendation?

A 20-year-old G1P1 is postpartum day 2 after an uncomplicated vaginal delivery of a 6-lb 10-oz baby boy. She is trying to decide whether to have you perform a circumcision on her newborn. The boy is in the well- baby nursery and is doing very well. In counseling this patient, you tell her which of the following recommendations from the American Pediatric Association?

You are counseling a new mother and father on the risks and benefits of circumcision for their 1-day-old son. The parents ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?

You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant?

You are making rounds on a 29-year-old G1P1 who underwent an uncomplicated vaginal delivery at term on the previous day. The patient is still very confused about whether she wants to breast-feed. She is a very busy lawyer and is planning on going back to work in 4 weeks, and she does not think that she has the time and dedication that breast-feeding requires. She asks you what you think is best for her to do. Which of the following is an accurate statement regarding breast-feeding?

A 22-year-old G1P1 who is postpartum day 2 and is bottle-feeding complains that her breasts are very engorged and tender. She wants you to give her something to make the engorgement go away. Which of the following is recommended to relieve her symptoms?

A 36-year-old G1P1 comes to see you for a routine postpartum exam- ination 6 weeks after an uncomplicated vaginal delivery. She is currently nursing her baby without any major problems and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for birth control. She does not have any medical problems. She is a nonsmoker and is not taking any medications except for her prenatal vitamins. Which of the following methods may decrease her milk supply?

A 30-year-old G3P3, who is 8 weeks postpartum and regularly breast-feeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness. Which of the following should you recommend to help her with this problem?

A 25-year-old G1P1 comes to see you 6 weeks after an uncompli- cated vaginal delivery for a routine postpartum examination. She denies any problems and has been breast-feeding her newborn without any diffi- culties since leaving the hospital. During the bimanual examination, you note that her uterus is irregular, firm, nontender, and about a 15-week size. Which of the following is the most likely etiology for this enlarged uterus?

A 39-year-old G3P3 comes to see you on day 5 after a second repeat cesarean delivery. She is concerned because her incision has become very red and tender and pus started draining from a small opening in the inci- sion this morning. She has been experiencing general malaise and reports a fever of 38.8°C (102°F). Physical examination indicates that the Pfan- nenstiel incision is indeed erythematous and is open about 1 cm at the left corner, and is draining a small amount of purulent liquid. There is tender- ness along the wound edges. Which of the following is the best next step in the management of this patient?

A 30-year-old G3P3 is postoperative day 4 after a repeat cesarean delivery. During the surgery she received 2 units of packed red blood cells for a hemorrhage related to uterine atony. She is to be discharged home today. She complains of some yellowish drainage from her incision and redness that just started earlier in the day. She states that she feels feverish. She is breast-feeding. Her past medical history is significant for type 2 dia- betes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8°C (100.1°F), pulse 69 beats per minute, respi- ratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Breast, lung, and cardiac examinations are normal. Her midline vertical skin incision is erythematous and has a foul-smelling purulent discharge from the lower segment of the wound. It is tender to touch. The uterine fundus is not tender. Which of the following is not a risk factor for her condition?

You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was nor- mal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?

A 74-year-old woman presents to your office for well-woman exam- ination. Her last Pap smear and mammogram were 3 years ago. She has hypertension, high cholesterol, and osteoarthritis. She stopped smoking 15 years ago, and denies alcohol use. Based on this patient’s history which of the following medical conditions should be this patient’s biggest concern?

A 17-year-old G1P1 presents to your office for her yearly well- woman examination. She had an uncomplicated vaginal delivery last year. She has been sexually active for the past 4 years and has had six different sexual partners. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal dis- charge. She denies tobacco, alcohol, or illicit drug use. Which of the fol- lowing are appropriate screening tests for this patient?

A 26-year-old woman presents to your office for her well-woman examination. She denies any medical problems or prior surgeries. She states that her cycles are monthly. She is sexually active and uses oral contracep- tive pills for birth control. Her physical examination is normal. As part of preventive health maintenance, you recommend breast self-examination and instruct the patient how to do it. Which of the following is the best fre- quency and time to perform breast self-examinations?

A married 41-year-old G5P3114 presents to your office for a routine examination. She reports being healthy except for a history of migraine headaches. All her Pap smears have been normal. She developed gestational diabetes in her last pregnancy. She drinks alcohol socially, and admits to smoking occasionally. Her grandmother was diagnosed with ovarian cancer when she was in her fifties. Her blood pressure is 140/90 mm Hg; height is 5 ft 5 in; weight is 150 lb. Which of the following is the most common cause of death in women of this patient’s age?

A 36-year-old G2P2 presents for her well-woman examination. She has had two spontaneous vaginal deliveries without complications. Her largest child weighed 3500 g at birth. She uses oral contraceptive pills and denies any history of an abnormal Pap smear. She does not smoke, but drinks about four times per week. Her weight is 70 kg. Her vital signs are normal. After place- ment of the speculum, you note a clear cyst approximately 2.5 cm in size on the lateral wall of the vagina on the right side. The cyst is nontender and does not cause the patient any dyspareunia or discomfort. Which of the following is the most likely diagnosis of this mass?

A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix. Since that time, all of her Pap tests have been normal. What recommendation should you make regarding how frequently she should undergo Pap smear testing?

A 45-year-old G3P3 presents for her yearly examination. She last saw a doctor 7 years ago after she had her last child. She had three vaginal deliveries, the last of which was complicated by gestational diabetes and preeclampsia. She has not been sexually active in the past year. She once had an abnormal Pap smear for which she underwent cryotherapy. She denies any medical problems. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67. Which of the following is best screening approach for this patient?

A 30-year-woman presents to your office with the fear of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer. You discuss with her the risks factors and prevention for ovarian cancer. Which of the following can decrease a woman’s risk of ovarian cancer?

A 42-year-old G4P3104 presents for her well-woman examination. She has had three vaginal deliveries and one cesarean delivery for breech. She states her cycles are regular and denies any sexually transmitted diseases. Currently she and her husband use condoms, but they hate the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. She drinks and smokes socially. She weighs 78 kg, and her blood pressure is 142/89 mm Hg. During her office visit, you counsel the patient at length regarding birth control methods. Which of the following is the most appropriate contraceptive method for this patient?

A 48-year-old G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. She had a vaginal hysterectomy for fibroids and menorrhagia. She denies any medical problems, but has not seen a doctor in 6 years. Her family history is significant for stroke, dia- betes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 3 in tall, and weighs 85 kg. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and tem- perature 37°C (98.4°F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal. The next appropriate step in the management of this patient’s blood pressure is which of the following?

A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

A 54-year-old woman undergoes a laparotomy because of a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. Which of the following is the most appropriate intraoperative course of action?

A 58-year-old woman is seen for evaluation of a swelling in her right vulva. She has also noted pain in this area when walking and during coitus. At the time of pelvic examination, a mildly tender, fluctuant mass is noted just outside the introitus in the right vulva in the region of the Bartholin gland. Which of the following is the most appropriate treatment?

A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes. This patient is classified at which of the following stages?

A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you classify or stage this patient’s disease?

A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. The patient above now asks you for your advice on how to treat her cervical disease. Your best recommendation is for the patient to undergo which of the following?

A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

A 22-year-old G3P0030 obese female comes to your office for a rou- tine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at age 15. She has had three first-trimester voluntary pregnancy ter- minations. She uses Depo-Provera for birth control, and reports occasion- ally using condoms as well. She has a history of genital warts, but denies any prior history of abnormal Pap smears. The patient denies use of any illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. However, 3 weeks later you receive the results of her Pap smear, which shows a high-grade squamous intraepithe- lial lesion (HGSIL). Which of the following factors in this patient’s history does not increase her risk for cervical dysplasia?

A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An endometrial sampling done in the office shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound done at the hospital demonstrates multiple, large uterine fibroids. Which of the following is the best treatment option for this patient?

You see five postmenopausal patients in the clinic. Each patient has one of the conditions listed, and each patient wishes to begin hormone replacement therapy today. Which one of the following patients would you start on therapy at the time of this visit?

A mother brings her 12-year-old daughter in to your office for consul- tation. She is concerned because most of the other girls in her daughter’s class have already started their period. She thinks her daughter hasn’t shown any evidence of going into puberty yet. Knowing the usual first sign of the onset of puberty, you should ask the mother which of the following questions?

A 55-year-old woman presents to your office for consultation regard- ing her symptoms of menopause. She stopped having periods 8 months ago and is having severe hot flushes. The hot flushes are causing her considerable stress. What should you tell her regarding the psychological symptoms of the climacteric?

While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus. You explain that additional testing is necessary because of the woman’s increased risk of congenital anomalies in which organ system?

A 39-year-old G3P3 complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Results of endometrial biopsy are normal. Which of the following is the most likely diagnosis?

A 28-year-old G3P0 has a history of severe menstrual cramps, pro- longed, heavy periods, chronic pelvic pain, and painful intercourse. All of her pregnancies were spontaneous abortions in the first trimester. A hysterosalpingogram (HSG) she just had as part of the evaluation for recurrent abortion showed a large uterine septum. You have recommended surgical repair of the uterus. Of the patient’s symptoms, which is most likely to be corrected by resection of the uterine septum?

During the evaluation of infertility in a 25-year-old female, a ysterosalpingogram showed evidence of Asherman syndrome. Which one of the following symptoms would you expect this patient to have?

A couple presents for evaluation of primary infertility. The evaluation of the woman is completely normal. The husband is found to have a left varicocele. If the husband’s varicocele is the cause of the couple’s infertility, what would you expect to see when evaluating the husband’s semen analysis?

A 25-year-old woman presents to your office for evaluation of primary infertility. She has regular periods every 28 days. She has done testing at home with an ovulation kit, which suggests she is ovulating. A hysterosalpingogram demonstrates patency of both fallopian tubes. A progesterone level drawn in the mid–luteal phase is lower than expected. A luteal phase defect is suspected to be the cause of this patient’s infertility. Which of the following studies performed in the second half of the menstrual cycle is helpful in making this diagnosis?

A 45-year-old woman who had two normal pregnancies 15 and 18 years ago presents with the complaint of amenorrhea for 7 months. She expresses the desire to become pregnant again. After exclusion of pregnancy, which of the following tests is next indicated in the evaluation of this patient’s amenorrhea?

Which of the following pubertal events in girls is not estrogen dependent?

You suspect that your infertility patient has an inadequate luteal phase. She should undergo an endometrial biopsy on which day of her menstrual cycle?

You have recommended a postcoital test for your patient as part of her evaluation for infertility. She and her spouse should have sexual intercourse on which day of her menstrual cycle as part of postcoital testing?

You ask a patient to call your office during her next menstrual cycle to schedule a hysterosalpingogram as part of her infertility evaluation. Which day of the menstrual cycle is best for performing the hysterosalpingogram?

You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked. Which is the best day of the menstrual cycle to check her proges- terone level if you are trying to confirm ovulation?

An 86-year-old woman presents to your office for her well-woman examination. She has no complaints. On pelvic examination performed in the supine and upright positions, the patient has second-degree prolapse of the uterus. Which of the following is the best next step in the management of this patient?

An 81-year-old woman presents to your office complaining that her uterus fell out 2 months ago. She has multiple medical problems, includ- ing chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes significant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has com- plete procidentia of the uterus. Which of the following is the most appro- priate next step in the management of this patient?

A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of something hanging out of her vagina. She had a hysterectomy for benign indications at age 48. For the past few months, she has been experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal opening. Two weeks ago something fell out of the vagina. On pelvic examination, the patient has total eversion of the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is the best next step in the management of this patient?

A 28-year-old woman presents to your office with symptoms of a uri- nary tract infection. This is her second infection in 2 months. You treated the last infection with Bactrim DS for 3 days. Her symptoms never really improved. Now she has worsening lower abdominal discomfort, dysuria, and frequency. She has had no fever or flank pain. Physical examination shows only mild suprapubic tenderness. Which of the following is the best next step in the evaluation of this patient?

A 28-year-old G3P3 presents to your office for contraceptive coun- seling. She denies any medical problems or sexually transmitted diseases. You counsel her on the risks and benefits of all contraceptive methods. Which of the following is the most common form of contraception used by reproductive-age women in the United States?

A 20-year-old woman presents to your office for her well-woman examination. She has recently become sexually active and desires an effective contraceptive method. She has no medical problems, but family history is significant for breast cancer in a maternal aunt at the age of 42. She is worried about getting cancer from taking birth control pills. You discuss with her the risks and benefits of contraceptive pills. You tell her that which of the following neoplasms has been associated with the use of oral contraceptives?

An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examina- tion, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?

A 19-year-old woman presents for voluntary termination of pregnancy 6 weeks after her expected (missed) menses. She previously had reg- ular menses every 28 days. Pregnancy is confirmed by β-human chorionic gonadotropin (β-hCG), and ultrasound confirms expected gestational age. Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?

A 22-year-old nulliparous woman has recently become sexually active. She consults you because of painful coitus, with the pain located at the vaginal introitus. It is accompanied by painful involuntary contraction of the pelvic muscles. Other than confirmation of these findings, the pelvic examination is normal. Which of the following is the most common cause of this condition?

Five patients present for contraceptive counseling, each requesting that an IUD be inserted. Which of the following is a recognized contraindication to the insertion of an IUD?

A couple presents to your office to discuss permanent sterilization. They have three children and are sure they do not want any more. You discuss the risk and benefits of surgical sterilization. Which of the following statements is true regarding surgical sterilizations?

A couple presents to your office to discuss sterilization. They are very happy with their four children and do not want any more. You discuss with them the pros and cons of both female and male sterilization. The 34-year- old male undergoes a vasectomy. Which of the following is the most frequent immediate complication of this procedure?

A woman with multiple sexual partners.For above female patient seeking contraception, select the method that is medically contraindicated for that patient.

A woman with a history of deep vein thrombosis. For above female patient seeking contraception, select the method that is medically contraindicated for that patient.

A woman with moderate cystocele. For above female patient seeking contraception, select the method that is medically contraindicated for that patient.

A woman with severely reduced functional capacity as a result of chronic obstructive lung disease. For above female patient seeking contraception, select the method that is medically contraindicated for that patient.

A woman with a known latex allergy. For above female patient seeking contraception, select the method that is medically contraindicated for that patient.

Nausea during first cycle of pills. For above situation involving oral contraceptives, select the most appropriate response.

Pill forgotten for 1 day. For above situation involving oral contraceptives, select the most appropriate response.

Pill forgotten for 3 continuous days. For above situation involving oral contraceptives, select the most appropriate response.

Light bleeding at midcycle during first month on pill. For above situation involving oral contraceptives, select the most appropriate response.

A 20-year-old woman presents to your office with the complaint of abdominal pain. Through further questioning, the woman reveals that she was sexually assaulted at a party 3 weeks ago by a male friend whom she recently started dating. She states that she has not revealed this to anyone else and has not informed the police because she was drinking. Her abdominal and pelvic examinations are normal. Which of the following is the best management to offer this patient?

You are called to the emergency department to evaluate an 18-year- old woman for a vulvar laceration. She is accompanied by her mother and father. The father explains that the injury was caused by a fall onto the sup- port bar on her bicycle. You interview the woman alone and find out that her father has been sexually assaulting her. Which of the following statements best describes injuries related to sexual assault?

You are an intern working the night shift in the emergency department. During the evaluation of a sexual assault victim, your attending physician asks you to order the appropriate laboratory tests. Which of the following tests should be ordered?

You are evaluating a 19-year-old woman for a sexual assault. She denies any medical problems or allergies to medications. Her pregnancy test is negative. Which of the following antibiotic prophylaxes do you recommend for sexually transmitted infections?

After your evaluation and treatment of a rape victim has been com- pleted, you discharge the patient to home. When is the best time to schedule a follow-up appointment for the patient?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal. The patient asks you about birth plans during her initial visit and inquires as to your attitudes toward pregnant couples who wish to participate in decision making regarding the conduct of labor and delivery. How would you respond?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal. The couple inquires about the routine administration of intravenous (IV) fluids during labor. Concerning this issue, which of the following statements is false?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal. The patient tells you it is very important to her that she has a “natural” delivery and does not want any narcotics or medications that will “hurt the baby.” How do you respond?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal.The couple has some specific requests that they add to their birth plan at the 36-week visit, suggested by a friend. Which of the following would not be advisable?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal. The couple’s final question concerns “routine episiotomy.” They have been told that the medical profession is “cut happy” and that the vast majority of episiotomies are unnecessary. Which of the following statements regarding routine episiotomy is true?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal. Which of the following is (are) an indication for the performance of an episiotomy?

A 22-year-old woman comes to your office at 10 weeks of gestation for her initial prenatal visit. She has been referred to you by friends who are your patients. She would like you to be her physician, deliver her baby, and then care for her child. Her uterus feels 10 weeks by size on bimanual exam, and her blood pressure is 100/70 mmHg. All other aspects of the initial complete physical examination are normal.7. Which of the following statements regarding the presence or absence of a supportive person (or coach) in labor is true?

A 30-year-old woman, on her first office visit, expresses her wish to become pregnant. She has never been pregnant, denies any chronic health conditions, is not overweight, and exercises regularly. As you seek further information to assist you in providing care, the following issues arise. You discuss with your patient the risk factors for adverse pregnancy outcome. Which of the following would increase the risk during her pregnancy?

A 30-year-old woman, on her first office visit, expresses her wish to become pregnant. She has never been pregnant, denies any chronic health conditions, is not overweight, and exercises regularly. As you seek further information to assist you in providing care, the following issues arise. Which of the following presents a risk during the pregnancy?

A 30-year-old woman, on her first office visit, expresses her wish to become pregnant. She has never been pregnant, denies any chronic health conditions, is not overweight, and exercises regularly. As you seek further information to assist you in providing care, the following issues arise. During the physical examination, which of the following findings increase(s) the risk of the pregnancy?

A 30-year-old woman, on her first office visit, expresses her wish to become pregnant. She has never been pregnant, denies any chronic health conditions, is not overweight, and exercises regularly. As you seek further information to assist you in providing care, the following issues arise. The patient relates to you that her sister had a baby who suffered from spina bifida. She questions the efficacy of folic acid:

A 37-year-old female sees you for her first office visit. She is interested in having a yearly Pap and mammogram. A comprehensive preconception care counseling will include which of the following?

Primigravida at 8 Weeks of Gestation. A 24-year-old primigravida comes to your office at 8 weeks of gestation for her first prenatal visit. She has asked you to be her family doctor and to look after her during the entire pregnancy. You agree to provide her pregnancy care. During your first visit, you explain your general philosophy regarding prenatal care and perinatal care. Which of the following regarding routine prenatal care is true?

A 24-year-old primigravida comes to your office at 8 weeks of gestation for her first prenatal visit. She has asked you to be her family doctor and to look after her during the entire pregnancy. You agree to provide her pregnancy care. During your first visit, you explain your general philosophy regarding prenatal care and perinatal care. Your patient had the first day of her last menstrual period on September 9, 2006. According to Nägele’s rule, what is the patient’s estimated date of delivery (assume a 28-day cycle)?

A 24-year-old primigravida comes to your office at 8 weeks of gestation for her first prenatal visit. She has asked you to be her family doctor and to look after her during the entire pregnancy. You agree to provide her pregnancy care. During your first visit, you explain your general philosophy regarding prenatal care and perinatal care. Which of the following tests are not recommended at her initial prenatal visit?

After discussion of the visits and tests that will be done during the pregnancy, your patient indicates that she is concerned about “getting fat.” She has been a smoker since age 16 years in an attempt to remain thin and she assumes she will continue to smoke after she delivers. She is concerned about breast-feeding for the same reason since people have told her that she would “have to eat for the baby” if she breast-feeds. She is 1.55 m tall and weighs 59 kg. How much weight gain do you recommend?

After discussion of the visits and tests that will be done during the pregnancy, your patient indicates that she is concerned about “getting fat.” She has been a smoker since age 16 years in an attempt to remain thin and she assumes she will continue to smoke after she delivers. She is concerned about breast-feeding for the same reason since people have told her that she would “have to eat for the baby” if she breast-feeds.17. In counseling your patients on weight, which of the following is not a complication associated with excessive weight gain?

After discussion of the visits and tests that will be done during the pregnancy, your patient indicates that she is concerned about “getting fat.” She has been a smoker since age 16 years in an attempt to remain thin and she assumes she will continue to smoke after she delivers. She is concerned about breast-feeding for the same reason since people have told her that she would “have to eat for the baby” if she breast-feeds.18. Which of the following statements would not be regarded as reasonable nutritional advice for your patient?

After discussion of the visits and tests that will be done during the pregnancy, your patient indicates that she is concerned about “getting fat.” She has been a smoker since age 16 years in an attempt to remain thin and she assumes she will continue to smoke after she delivers. She is concerned about breast-feeding for the same reason since people have told her that she would “have to eat for the baby” if she breast-feeds.19. Which of the following statements regarding smoking in pregnancy is true?

A 35-year-old woman and her husband have been attempting to get pregnant without success. They had considered pursuing a fertility workup but were concerned about the expense. They had begun the process for adoption, but she has had a positive home pregnancy test, and based on her last menstrual period (LMP) she is 6 weeks pregnant. She is in good health and takes no medication except for a multivitamin. Which of the following statements is (are) true concerning current recommendations on routine prenatal visits?

A Pregnant Woman Concerned about Consuming Ibuprofen A newly pregnant woman who comes to the office is very concerned about the fact that she took ibuprofen for a headache during the past week. She is asking whether it is safe to take during pregnancy. Which of the following statements about taking ibuprofen during pregnancy is true?

An 18-year-old primigravida comes to your office for her initial prenatal visit. The pregnancy was unanticipated and she is quite disconcerted. She denies any medical problems or prior surgery. Her body mass index is 29. She has been taking prenatal vitamins for 1 month. Her mother hands you a list of symptoms that are bothering her daughter. The patient is quite nauseated and “throws up constantly.” She dramatically states that she has lost “at least 10 pounds in the past 6 weeks.” Neither “preggie pops” nor the “wrist bands she bought at the pharmacy” help. She desires other options for ending the nausea. Other complaints include blurred vision, bleeding gums, and a vaginal discharge. Her mother is concerned that she contracted a sexually transmitted disease from her boyfriend. The patient informs you that she had a well woman exam 2 months ago. The Pap exam was normal and cultures for gonorrhea and chlamydia were negative. On physical examination, the patient is well hydrated and has actually gained 6 pounds. The uterus is 10 weeks’ size. The cervix is closed, firm, and not effaced. There is a whitish copious discharge but no odor or cervical motion tenderness. The remainder of her physical exam, including a urinalysis, is normal. Which of the following hormones is thought to have the greatest influence on nausea and vomiting in pregnancy (NVP)?

An 18-year-old primigravida comes to your office for her initial prenatal visit. The pregnancy was unanticipated and she is quite disconcerted. She denies any medical problems or prior surgery. Her body mass index is 29. She has been taking prenatal vitamins for 1 month. Her mother hands you a list of symptoms that are bothering her daughter. The patient is quite nauseated and “throws up constantly.” She dramatically states that she has lost “at least 10 pounds in the past 6 weeks.” Neither “preggie pops” nor the “wrist bands she bought at the pharmacy” help. She desires other options for ending the nausea. Other complaints include blurred vision, bleeding gums, and a vaginal discharge. Her mother is concerned that she contracted a sexually transmitted disease from her boyfriend. The patient informs you that she had a well woman exam 2 months ago. The Pap exam was normal and cultures for gonorrhea and chlamydia were negative. On physical examination, the patient is well hydrated and has actually gained 6 pounds. The uterus is 10 weeks’ size. The cervix is closed, firm, and not effaced. There is a whitish copious discharge but no odor or cervical motion tenderness. The remainder of her physical exam, including a urinalysis, is normal. Which of the following would not be indicated as initial advice or treatment for women with NVP?

An 18-year-old primigravida comes to your office for her initial prenatal visit. The pregnancy was unanticipated and she is quite disconcerted. She denies any medical problems or prior surgery. Her body mass index is 29. She has been taking prenatal vitamins for 1 month. Her mother hands you a list of symptoms that are bothering her daughter. The patient is quite nauseated and “throws up constantly.” She dramatically states that she has lost “at least 10 pounds in the past 6 weeks.” Neither “preggie pops” nor the “wrist bands she bought at the pharmacy” help. She desires other options for ending the nausea. Other complaints include blurred vision, bleeding gums, and a vaginal discharge. Her mother is concerned that she contracted a sexually transmitted disease from her boyfriend. The patient informs you that she had a well woman exam 2 months ago. The Pap exam was normal and cultures for gonorrhea and chlamydia were negative. On physical examination, the patient is well hydrated and has actually gained 6 pounds. The uterus is 10 weeks’ size. The cervix is closed, firm, and not effaced. There is a whitish copious discharge but no odor or cervical motion tenderness. The remainder of her physical exam, including a urinalysis, is normal. Which of the following remedies is no more effective than placebo in reducing symptoms of NVP?

An 18-year-old primigravida comes to your office for her initial prenatal visit. The pregnancy was unanticipated and she is quite disconcerted. She denies any medical problems or prior surgery. Her body mass index is 29. She has been taking prenatal vitamins for 1 month. Her mother hands you a list of symptoms that are bothering her daughter. The patient is quite nauseated and “throws up constantly.” She ramatically states that she has lost “at least 10 pounds in the past 6 weeks.” Neither “preggie pops” nor the “wrist bands she bought at the pharmacy” help. She desires other options for ending the nausea. Other complaints include blurred vision, bleeding gums, and a vaginal discharge. Her mother is concerned that she contracted a sexually transmitted disease from her boyfriend. The patient informs you that she had a well woman exam 2 months ago. The Pap exam was normal and cultures for gonorrhea and chlamydia were negative. On physical examination, the patient is well hydrated and has actually gained 6 pounds. The uterus is 10 weeks’ size. The cervix is closed, firm, and not effaced. There is a whitish copious discharge but no odor or cervical motion tenderness. The remainder of her physical exam, including a urinalysis, is normal. How should the patient be counseled regarding her vaginal discharge?

A 36-year-old multigravida at 34 weeks of gestation. She works as a stockbroker at a large brokerage house. During the past 2 weeks, she has developed worsening edema in her bilateral lower extremities. It is worse at the end of the day and generally resolves somewhat by the next morning. Although XYZ has made some lifestyle changes (she no longer wears high heels to work), the symptoms are getting worse. At her routine visit, she is concerned about “severe abdominal pain.” She describes the pain as inguinal, stabbing, and intermittent. XYZ comments that she also has significant low back pain. The pain is dull, constant, and located over the lower lumbar spine. She has no loss of bladder or bowel function and no neurologic abnormalities on exam. The low back pain is not related to the inguinal pain. Which of the following statements about lower extremity edema during pregnancy is true?

A 34-year-old female (gravida 2, para 1) presents to the clinic with bleeding during pregnancy. She reports that it has been 6 weeks since her last menstrual period. She had a positive home pregnancy test 1 week ago and is scheduled for her first obstetrical appointment in 3 weeks. She is complaining of light vaginal bleeding without abdominal cramping or backache. She states that her symptoms began this morning. She has no orthostatic symptoms. There are no other systemic symptoms, including fever, abdominal pain, or vomiting. Her previous medical and obstetrical history is uncomplicated. Physical examination shows that she is tearful. Vital signs reveal temperature 97.8°F, pulse 76 beats/minute, blood pressure 126/78 mmHg, and respiratory rate 20 breaths/minute. Her vital signs do not significantly change with orthostatic testing. Her abdomen is soft and flat. She has active bowel sounds. Pelvic examination shows a small amount of bright red bleeding coming from the cervical os. The uterus is parous and consistent with her dating history. Adnexal structures are normal to bimanual exam. Her urine pregnancy test is positive. Vaginal bleeding in pregnancy before 20 weeks of gestation is defined as

A 34-year-old female (gravida 2, para 1) presents to the clinic with bleeding during pregnancy. She reports that it has been 6 weeks since her last menstrual period. She had a positive home pregnancy test 1 week ago and is scheduled for her first obstetrical appointment in 3 weeks. She is complaining of light vaginal bleeding without abdominal cramping or backache. She states that her symptoms began this morning. She has no orthostatic symptoms. There are no other systemic symptoms, including fever, abdominal pain, or vomiting. Her previous medical and obstetrical history is uncomplicated. Physical examination shows that she is tearful. Vital signs reveal temperature 97.8°F, pulse 76 beats/minute, blood pressure 126/78 mmHg, and respiratory rate 20 breaths/minute. Her vital signs do not significantly change with orthostatic testing. Her abdomen is soft and flat. She has active bowel sounds. Pelvic examination shows a small amount of bright red bleeding coming from the cervical os. The uterus is parous and consistent with her dating history. Adnexal structures are normal to bimanual exam. Her urine pregnancy test is positive.Which of the following conditions is the most common complication of a recognized pregnancy in Cambodia?

A 34-year-old female (gravida 2, para 1) presents to the clinic with bleeding during pregnancy. She reports that it has been 6 weeks since her last menstrual period. She had a positive home pregnancy test 1 week ago and is scheduled for her first obstetrical appointment in 3 weeks. She is complaining of light vaginal bleeding without abdominal cramping or backache. She states that her symptoms began this morning. She has no orthostatic symptoms. There are no other systemic symptoms, including fever, abdominal pain, or vomiting. Her previous medical and obstetrical history is uncomplicated. Physical examination shows that she is tearful. Vital signs reveal temperature 97.8°F, pulse 76 beats/minute, blood pressure 126/78 mmHg, and respiratory rate 20 breaths/minute. Her vital signs do not significantly change with orthostatic testing. Her abdomen is soft and flat. She has active bowel sounds. Pelvic examination shows a small amount of bright red bleeding coming from the cervical os. The uterus is parous and consistent with her dating history. Adnexal structures are normal to bimanual exam. Her urine pregnancy test is positive.In the management of this patient, you decide she is clinically stable. The local hospital is able to provide timely testing for you. Which of the following tests is least helpful at this time?

A 34-year-old female (gravida 2, para 1) presents to the clinic with bleeding during pregnancy. She reports that it has been 6 weeks since her last menstrual period. She had a positive home pregnancy test 1 week ago and is scheduled for her first obstetrical appointment in 3 weeks. She is complaining of light vaginal bleeding without abdominal cramping or backache. She states that her symptoms began this morning. She has no orthostatic symptoms. There are no other systemic symptoms, including fever, abdominal pain, or vomiting. Her previous medical and obstetrical history is uncomplicated. Physical examination shows that she is tearful. Vital signs reveal temperature 97.8°F, pulse 76 beats/minute, blood pressure 126/78 mmHg, and respiratory rate 20 breaths/minute. Her vital signs do not significantly change with orthostatic testing. Her abdomen is soft and flat. She has active bowel sounds. Pelvic examination shows a small amount of bright red bleeding coming from the cervical os. The uterus is parous and consistent with her dating history. Adnexal structures are normal to bimanual exam. Her urine pregnancy test is positive.During a follow-up visit at your clinic, this patient notes that bleeding has stopped. She has no pain or cramping. Her testing shows a quantitative -hCG level of 950 mIU/mL, and no gestational sac is noted on pelvic ultrasound. You decide to do the following:

A 28-year-old (gravida 1, para 0) patient comes to see you for a follow-up clinic visit. She experienced vaginal bleeding in early pregnancy. Initially, she presented with light vaginal bleeding at 10 weeks of gestation. Her initial ultrasound was reassuring, with normal fetal growth and definite heartbeat. A few days later, she began having heavy bleeding. Follow-up testing showed an incomplete abortion. You discussed surgical, medical, and expectant management. She chose expectant management and is here for follow-up. Many women choose expectant management for spontaneous abortion. Which of the following statements is true when comparing expectant management with surgical management of a spontaneous abortion?

A 28-year-old (gravida 1, para 0) patient comes to see you for a follow-up clinic visit. She experienced vaginal bleeding in early pregnancy. Initially, she presented with light vaginal bleeding at 10 weeks of gestation. Her initial ultrasound was reassuring, with normal fetal growth and definite heartbeat. A few days later, she began having heavy bleeding. Follow-up testing showed an incomplete abortion. You discussed surgical, medical, and expectant management. She chose expectant management and is here for follow-up. Medical regimens exist as treatment options for spontaneous abortion. Misoprostol is part of many of these regimens. Which of the following statements is (are) true regarding use of misoprostol in the medical management of spontaneous abortion?

A 28-year-old (gravida 1, para 0) patient comes to see you for a follow-up clinic visit. She experienced vaginal bleeding in early pregnancy. Initially, she presented with light vaginal bleeding at 10 weeks of gestation. Her initial ultrasound was reassuring, with normal fetal growth and definite heartbeat. A few days later, she began having heavy bleeding. Follow-up testing showed an incomplete abortion. You discussed surgical, medical, and expectant management. She chose expectant management and is here for follow-up. In an uncomplicated pregnancy, which of the following factors does not increase the risk for spontaneous abortion?

A 28-year-old (gravida 1, para 0) patient comes to see you for a follow-up clinic visit. She experienced vaginal bleeding in early pregnancy. Initially, she presented with light vaginal bleeding at 10 weeks of gestation. Her initial ultrasound was reassuring, with normal fetal growth and definite heartbeat. A few days later, she began having heavy bleeding. Follow-up testing showed an incomplete abortion. You discussed surgical, medical, and expectant management. She chose expectant management and is here for follow-up.The patient continues to be managed expectantly and experiences a completed spontaneous abortion without need for surgical instrumentation. She is now concerned that she will experience recurrent abortion. What is the definition of recurrent abortion?

A 28-year-old (gravida 1, para 0) patient comes to see you for a follow-up clinic visit. She experienced vaginal bleeding in early pregnancy. Initially, she presented with light vaginal bleeding at 10 weeks of gestation. Her initial ultrasound was reassuring, with normal fetal growth and definite heartbeat. A few days later, she began having heavy bleeding. Follow-up testing showed an incomplete abortion. You discussed surgical, medical, and expectant management. She chose expectant management and is here for follow-up.In the 6 months following miscarriage, women are at increased risk for which of the following disorders?

The patient is a 23-year-old woman whose family has a history of diabetes mellitus. She is currently 28 weeks of gestation. Your patient goes into labor at 40 weeks of gestation, gradually increasing to fully dilated. She then pushes for 3 hours until you elect to do a vacuum extraction because of maternal exhaustion. You notice immediate “turtling” of the infant’s head. The following are appropriate steps in using a vacuum extractor except:

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema. Her diagnosis is

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.The patient wants to know if she has an increased risk in this pregnancy. Your explain that:

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema. The appropriate course of action to evaluate her elevated blood pressure includes.

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Your patient calls you at night complaining of a severe headache and thinks she is seeing “double.” She is now 30 weeks pregnant. You tell her to go to the emergency room. Your presumptive diagnosis is

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.The patient’s blood pressure in the emergency room is 160/110 mmHg, and she has severe pedal edema and hyperflexia. You will

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Fetal indications for delivery of this patient’s baby include all the following except:

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Treatment of acute severe hypertension (sustained blood pressures higher than 160 systolic and 105 diastolic) in pregnancy include the following except:

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.The patient complains of a severe headache during labor, her blood pressure climbs to 150/100 mmHg, and she now has 3+ protein on a urine sample collected by the nurse. The most appropriate treatment for your patient at this time would be

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Which of the following statements regarding eclampsia is true?

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Which one of the following intrapartum conditions is associated with preeclampsia/eclampsia?

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Which of the following are risks for recurrence of preeclampsia?

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.The patient delivers vaginally. The following are considered steps to use in the active management of the third stage of labor except

A Primigravida with Hypertension. A 35-year-old pregnant woman (gravida 2, para 1) comes into the office for her 18-week prenatal appointment. Her blood pressure is 140/94 mmHg when taken by your nurse and is confirmed by your own measurement. She has no protein in her urine and has no headaches, blurred vision, nausea, or vomiting. The rest of the examination is consistent with dates; there is no lower extremity edema.Risk factors for postpartum hemorrhage include

MB is a 24-year-old (gravida 1, para 0) female who is 30 weeks pregnant. Her last menstrual period is certain. She presented for care at 9 weeks of gestation and has kept her monthly follow-up appointments. Her initial body mass index was 21, and she has gained 3kg during the past 8 weeks. Fundal height has been consistent with dates, but today the fundal measurement is 25 cm. She smokes one and a half packs of cigarettes a day and is unable to cut down. She denies alcohol or other substance use. She denies any recent infections. An ultrasound at 16 weeks was consistent with her last menstrual period and showed normal fetal anatomy. A repeat ultrasound shows estimated fetal weight consistent with a 25-week gestation (fetal weight below the 10th percentile for 30-week gestation). The amniotic fluid index is normal.Which of the following statements regarding intrauterine growth restriction (IUGR) is true?

MB is a 24-year-old (gravida 1, para 0) female who is 30 weeks pregnant. Her last menstrual period is certain. She presented for care at 9 weeks of gestation and has kept her monthly follow-up appointments. Her initial body mass index was 21, and she has gained 3kg during the past 8 weeks. Fundal height has been consistent with dates, but today the fundal measurement is 25 cm. She smokes one and a half packs of cigarettes a day and is unable to cut down. She denies alcohol or other substance use. She denies any recent infections. An ultrasound at 16 weeks was consistent with her last menstrual period and showed normal fetal anatomy. A repeat ultrasound shows estimated fetal weight consistent with a 25-week gestation (fetal weight below the 10th percentile for 30-week gestation). The amniotic fluid index is normal.What is the leading cause of fetal growth restriction in human pregnancies?

A 24-year-old (gravida 1, para 0) female who is 30 weeks pregnant. Her last menstrual period is certain. She presented for care at 9 weeks of gestation and has kept her monthly follow-up appointments. Her initial body mass index was 21, and she has gained 3kg during the past 8 weeks. Fundal height has been consistent with dates, but today the fundal measurement is 25 cm. She smokes one and a half packs of cigarettes a day and is unable to cut down. She denies alcohol or other substance use. She denies any recent infections. An ultrasound at 16 weeks was consistent with her last menstrual period and showed normal fetal anatomy. A repeat ultrasound shows estimated fetal weight consistent with a 25-week gestation (fetal weight below the 10th percentile for 30-week gestation). The amniotic fluid index is normal.All of the following types of maternal substance use are linked with IUGR except

A 35-year-old (gravida 1, para 0) female visits your office at 40 weeks of gestation. Her last menstrual period (LMP) is “certain.” Her history is significant for regular menstrual cycles and no oral contraceptive use within 3 months of becoming pregnant. A 13-week ultrasound was consistent with her LMP. The pregnancy has been unremarkable. The patient is quite concerned because today is her due date and she is not in labor. She states that her mother did not “go into labor until after 44 weeks” and she is worried that “late babies run in the family.” On physical examination, fundal height is 39 cm. Her weight has increased by 1 pound and vital signs are stable. Fetal heart tones are 140. The cervix is closed, thick, and high. Estimated fetal weight is 3.5kg. Which of the following gestational ages is considered post-term?

A 35-year-old (gravida 1, para 0) female visits your office at 40 weeks of gestation. Her last menstrual period (LMP) is “certain.” Her history is significant for regular menstrual cycles and no oral contraceptive use within 3 months of becoming pregnant. A 13-week ultrasound was consistent with her LMP. The pregnancy has been unremarkable. The patient is quite concerned because today is her due date and she is not in labor. She states that her mother did not “go into labor until after 44 weeks” and she is worried that “late babies run in the family.” On physical examination, fundal height is 39 cm. Her weight has increased by 1 pound and vital signs are stable. Fetal heart tones are 140. The cervix is closed, thick, and high. Estimated fetal weight is 3.5kg.Which of the following conditions is not associated with increased risk of post-term pregnancy?

A 35-year-old (gravida 1, para 0) female visits your office at 40 weeks of gestation. Her last menstrual period (LMP) is “certain.” Her history is significant for regular menstrual cycles and no oral contraceptive use within 3 months of becoming pregnant. A 13-week ultrasound was consistent with her LMP. The pregnancy has been unremarkable. The patient is quite concerned because today is her due date and she is not in labor. She states that her mother did not “go into labor until after 44 weeks” and she is worried that “late babies run in the family.” On physical examination, fundal height is 39 cm. Her weight has increased by 1 pound and vital signs are stable. Fetal heart tones are 140. The cervix is closed, thick, and high. Estimated fetal weight is 3.5kg.What is the most common cause of post-term pregnancy?

A 35-year-old (gravida 1, para 0) female visits your office at 40 weeks of gestation. Her last menstrual period (LMP) is “certain.” Her history is significant for regular menstrual cycles and no oral contraceptive use within 3 months of becoming pregnant. A 13-week ultrasound was consistent with her LMP. The pregnancy has been unremarkable. The patient is quite concerned because today is her due date and she is not in labor. She states that her mother did not “go into labor until after 44 weeks” and she is worried that “late babies run in the family.” On physical examination, fundal height is 39 cm. Her weight has increased by 1 pound and vital signs are stable. Fetal heart tones are 140. The cervix is closed, thick, and high. Estimated fetal weight is 3.5kg.The patient progresses to 41 weeks. She now wants to be managed expectantly because she heard that the risk of cesarean is higher if she is induced. Which of the following statements about labor induction at 41 weeks is not true?

A 35-year-old (gravida 1, para 0) female visits your office at 40 weeks of gestation. Her last menstrual period (LMP) is “certain.” Her history is significant for regular menstrual cycles and no oral contraceptive use within 3 months of becoming pregnant. A 13-week ultrasound was consistent with her LMP. The pregnancy has been unremarkable. The patient is quite concerned because today is her due date and she is not in labor. She states that her mother did not “go into labor until after 44 weeks” and she is worried that “late babies run in the family.” On physical examination, fundal height is 39 cm. Her weight has increased by 1 pound and vital signs are stable. Fetal heart tones are 140. The cervix is closed, thick, and high. Estimated fetal weight is 3.5kg.The patient agrees to proceed with labor induction. Her cervical exam at this time is as follows: 2-cm dilation, 60% effacement, −2 station, firm consistency, and posterior. Which of the following statements is correct?

A 35-year-old (gravida 1, para 0) female visits your office at 40 weeks of gestation. Her last menstrual period (LMP) is “certain.” Her history is significant for regular menstrual cycles and no oral contraceptive use within 3 months of becoming pregnant. A 13-week ultrasound was consistent with her LMP. The pregnancy has been unremarkable. The patient is quite concerned because today is her due date and she is not in labor. She states that her mother did not “go into labor until after 44 weeks” and she is worried that “late babies run in the family.” On physical examination, fundal height is 39 cm. Her weight has increased by 1 pound and vital signs are stable. Fetal heart tones are 140. The cervix is closed, thick, and high. Estimated fetal weight is 3.5kg.Which of the following statements about the use of prostaglandin for cervical ripening is incorrect?

An 18-year-old (gravida 1) female at 39 weeks and 5 days gestation. The pregnancy has been uneventful. She arrives on the floor with her mother, boyfriend, and two friends. Her presenting complaint is contractions for 3 hours. The contractions are 5 minutes apart and irregular. She denies bleeding, fluid leakage, or decreased fetal movement. On physical examination, her cervix is dilated to 3 cm and is 20% effaced, firm, and posterior. A non-stress test is reassuring. She is monitored for 2 hours and has no significant cervical change. 59. Women admitted to labor and delivery in this patient’s stage of labor are at increased risk for all of the following except

An 18-year-old (gravida 1) female at 39 weeks and 5 days gestation. The pregnancy has been uneventful. She arrives on the floor with her mother, boyfriend, and two friends. Her presenting complaint is contractions for 3 hours. The contractions are 5 minutes apart and irregular. She denies bleeding, fluid leakage, or decreased fetal movement. On physical examination, her cervix is dilated to 3 cm and is 20% effaced, firm, and posterior. A non-stress test is reassuring. She is monitored for 2 hours and has no significant cervical change.What is the working diagnosis at this time?

An 18-year-old (gravida 1) female at 39 weeks and 5 days gestation. The pregnancy has been uneventful. She arrives on the floor with her mother, boyfriend, and two friends. Her presenting complaint is contractions for 3 hours. The contractions are 5 minutes apart and irregular. She denies bleeding, fluid leakage, or decreased fetal movement. On physical examination, her cervix is dilated to 3 cm and is 20% effaced, firm, and posterior. A non-stress test is reassuring. She is monitored for 2 hours and has no significant cervical change.Which of the following outcomes is not associated with continuity of care during pregnancy?

The patient is sent home. She returns 2 days later with continued contractions that are now 3 minutes apart and regular. On sterile vaginal exam, her cervix is 4 cm dilated, 50% effaced, −2 position, mid-station, and soft. The patient is admitted to labor and delivery. Her mother and boyfriend are quite excited and want to know exactly when the baby will deliver. The patient wants to talk about whether an epidural is a good idea. Her mother wants to know when her daughter will receive an enema and “be shaved.” She also warns the patient that an episiotomy is required for the baby to deliver safely. What is the expected rate of cervical dilatation during active labor in nulliparous women?

The patient is sent home. She returns 2 days later with continued contractions that are now 3 minutes apart and regular. On sterile vaginal exam, her cervix is 4 cm dilated, 50% effaced, −2 position, mid-station, and soft. The patient is admitted to labor and delivery. Her mother and boyfriend are quite excited and want to know exactly when the baby will deliver. The patient wants to talk about whether an epidural is a good idea. Her mother wants to know when her daughter will receive an enema and “be shaved.” She also warns the patient that an episiotomy is required for the baby to deliver safely.Which statement regarding active management of labor is false?

The patient is sent home. She returns 2 days later with continued contractions that are now 3 minutes apart and regular. On sterile vaginal exam, her cervix is 4 cm dilated, 50% effaced, −2 position, mid-station, and soft. The patient is admitted to labor and delivery. Her mother and boyfriend are quite excited and want to know exactly when the baby will deliver. The patient wants to talk about whether an epidural is a good idea. Her mother wants to know when her daughter will receive an enema and “be shaved.” She also warns the patient that an episiotomy is required for the baby to deliver safely.Which of these types of general care during labor is supported by evidence-based studies?

The patient is sent home. She returns 2 days later with continued contractions that are now 3 minutes apart and regular. On sterile vaginal exam, her cervix is 4 cm dilated, 50% effaced, −2 position, mid-station, and soft. The patient is admitted to labor and delivery. Her mother and boyfriend are quite excited and want to know exactly when the baby will deliver. The patient wants to talk about whether an epidural is a good idea. Her mother wants to know when her daughter will receive an enema and “be shaved.” She also warns the patient that an episiotomy is required for the baby to deliver safely.Which of the following statements regarding amniotomy is true?

The patient is sent home. She returns 2 days later with continued contractions that are now 3 minutes apart and regular. On sterile vaginal exam, her cervix is 4 cm dilated, 50% effaced, −2 position, mid-station, and soft. The patient is admitted to labor and delivery. Her mother and boyfriend are quite excited and want to know exactly when the baby will deliver. The patient wants to talk about whether an epidural is a good idea. Her mother wants to know when her daughter will receive an enema and “be shaved.” She also warns the patient that an episiotomy is required for the baby to deliver safely.How should expectant women be counseled regarding episiotomy?

The patient is sent home. She returns 2 days later with continued contractions that are now 3 minutes apart and regular. On sterile vaginal exam, her cervix is 4 cm dilated, 50% effaced, −2 position, mid-station, and soft. The patient is admitted to labor and delivery. Her mother and boyfriend are quite excited and want to know exactly when the baby will deliver. The patient wants to talk about whether an epidural is a good idea. Her mother wants to know when her daughter will receive an enema and “be shaved.” She also warns the patient that an episiotomy is required for the baby to deliver safely.Which of the following is not included in active management of the third stage of labor?

A 27-year-old female (gravida 2, para 1) at 39 weeks of gestation presents to labor and delivery in active labor. Her pregnancy has been uncomplicated and her prior two deliveries were vaginal. Her cervix is checked by the nurse and judged to be 6 cm, 90% effaced, midposition, and soft. The fetus is not engaged and is thought to be vertex. Initial fetal monitoring shows a heart rate in the 140s with good accelerations and is reassuring. Contractions are 4 minutes apart and the patient is comfortable. Twenty minutes later, the patient experiences a large gush of clear fluid, and severe variable decelerations appear on the fetal heart rate monitor. What is the most likely diagnosis at this time?

A 27-year-old female (gravida 2, para 1) at 39 weeks of gestation presents to labor and delivery in active labor. Her pregnancy has been uncomplicated and her prior two deliveries were vaginal. Her cervix is checked by the nurse and judged to be 6 cm, 90% effaced, midposition, and soft. The fetus is not engaged and is thought to be vertex. Initial fetal monitoring shows a heart rate in the 140s with good accelerations and is reassuring. Contractions are 4 minutes apart and the patient is comfortable. Twenty minutes later, the patient experiences a large gush of clear fluid, and severe variable decelerations appear on the fetal heart rate monitor.Which of the following conditions is not considered a risk factor for cord prolapse?

A 27-year-old female (gravida 2, para 1) at 39 weeks of gestation presents to labor and delivery in active labor. Her pregnancy has been uncomplicated and her prior two deliveries were vaginal. Her cervix is checked by the nurse and judged to be 6 cm, 90% effaced, midposition, and soft. The fetus is not engaged and is thought to be vertex. Initial fetal monitoring shows a heart rate in the 140s with good accelerations and is reassuring. Contractions are 4 minutes apart and the patient is comfortable. Twenty minutes later, the patient experiences a large gush of clear fluid, and severe variable decelerations appear on the fetal heart rate monitor.Which of the following statements about cord prolapse diagnosis is false?

A 27-year-old female (gravida 2, para 1) at 39 weeks of gestation presents to labor and delivery in active labor. Her pregnancy has been uncomplicated and her prior two deliveries were vaginal. Her cervix is checked by the nurse and judged to be 6 cm, 90% effaced, midposition, and soft. The fetus is not engaged and is thought to be vertex. Initial fetal monitoring shows a heart rate in the 140s with good accelerations and is reassuring. Contractions are 4 minutes apart and the patient is comfortable. Twenty minutes later, the patient experiences a large gush of clear fluid, and severe variable decelerations appear on the fetal heart rate monitor.What is the recommended immediate management of this patient?

No Prenatal Care and Bleeding A 23-year-old female (gravida 6, para 3114) presents to labor and delivery with severe abdominal pain. She has no prenatal care, and she thinks her last menstrual period was approximately 9 months ago. She denies a history of medical problems or surgery. All previous deliveries were vaginal. She smokes one and a half packs of cigarettes a day and admits to remote “crank” use. Fundal height measures 39 cm, and there is copious bleeding from the vagina. The fetal monitor shows contractions every minute with elevated baseline uterine tone. Fetal tachycardia at 180 beats/minute, and late decelerations are also present.What is the most likely diagnosis?

No Prenatal Care and Bleeding. A 23-year-old female (gravida 6, para 3114) presents to labor and delivery with severe abdominal pain. She has no prenatal care, and she thinks her last menstrual period was approximately 9 months ago. She denies a history of medical problems or surgery. All previous deliveries were vaginal. She smokes one and a half packs of cigarettes a day and admits to remote “crank” use. Fundal height measures 39 cm, and there is copious bleeding from the vagina. The fetal monitor shows contractions every minute with elevated baseline uterine tone. Fetal tachycardia at 180 beats/minute, and late decelerations are also present.Maternal risks associated with this diagnosis include all of the following except

No Prenatal Care and Bleeding. A 23-year-old female (gravida 6, para 3114) presents to labor and delivery with severe abdominal pain. She has no prenatal care, and she thinks her last menstrual period was approximately 9 months ago. She denies a history of medical problems or surgery. All previous deliveries were vaginal. She smokes one and a half packs of cigarettes a day and admits to remote “crank” use. Fundal height measures 39 cm, and there is copious bleeding from the vagina. The fetal monitor shows contractions every minute with elevated baseline uterine tone. Fetal tachycardia at 180 beats/minute, and late decelerations are also present.Which gestational age has the highest incidence of placental abruption?

No Prenatal Care and Bleeding. A 23-year-old female (gravida 6, para 3114) presents to labor and delivery with severe abdominal pain. She has no prenatal care, and she thinks her last menstrual period was approximately 9 months ago. She denies a history of medical problems or surgery. All previous deliveries were vaginal. She smokes one and a half packs of cigarettes a day and admits to remote “crank” use. Fundal height measures 39 cm, and there is copious bleeding from the vagina. The fetal monitor shows contractions every minute with elevated baseline uterine tone. Fetal tachycardia at 180 beats/minute, and late decelerations are also present.Which of the following conditions is not strongly associated with placental abruption?

A 37-year-old female (gravida 2, para 1001) at 39 weeks of gestation progresses to complete and pushing. Her pregnancy has been complicated by type 2 diabetes, for which she takes metformin. She has gained 45 pounds during the pregnancy, despite both nutritional consultation and repeated counseling. She is 5 feet 2 inches tall and has a prepregnancy body mass index of 34. Descent of the fetal head is slower than anticipated with “positive turtle sign” during contractions. The head is delivered after 2 hours of pushing. The anterior shoulder is difficult to deliver without increased traction. Sixty seconds pass without successful delivery.What is the most important action to take at this time?

A 37-year-old female (gravida 2, para 1001) at 39 weeks of gestation progresses to complete and pushing. Her pregnancy has been complicated by type 2 diabetes, for which she takes metformin. She has gained 45 pounds during the pregnancy, despite both nutritional consultation and repeated counseling. She is 5 feet 2 inches tall and has a prepregnancy body mass index of 34. Descent of the fetal head is slower than anticipated with “positive turtle sign” during contractions. The head is delivered after 2 hours of pushing. The anterior shoulder is difficult to deliver without increased traction. Sixty seconds pass without successful delivery.Which of the following statements about shoulder dystocia is true?

A 37-year-old female (gravida 2, para 1001) at 39 weeks of gestation progresses to complete and pushing. Her pregnancy has been complicated by type 2 diabetes, for which she takes metformin. She has gained 45 pounds during the pregnancy, despite both nutritional consultation and repeated counseling. She is 5 feet 2 inches tall and has a prepregnancy body mass index of 34. Descent of the fetal head is slower than anticipated with “positive turtle sign” during contractions. The head is delivered after 2 hours of pushing. The anterior shoulder is difficult to deliver without increased traction. Sixty seconds pass without successful delivery.Which of the following statements regarding macrosomia and shoulder dystocia is true?

Hypotension and Bleeding after Delivery. The patient in Clinical Case Problem 3 delivers atraumatically using a combination of McRoberts’ maneuver, suprapubic pressure, and an episiotomy. Profuse vaginal bleeding is noted both prior to and following delivery of the placenta. The patient becomes lightheaded and tachycardic. Blood pressure drops to 60/40 mmHg.Which of the following is the least likely cause of this problem?

Hypotension and Bleeding after Delivery. The patient in Clinical Case Problem 3 delivers atraumatically using a combination of McRoberts’ maneuver, suprapubic pressure, and an episiotomy. Profuse vaginal bleeding is noted both prior to and following delivery of the placenta. The patient becomes lightheaded and tachycardic. Blood pressure drops to 60/40 mmHg.Which of the following steps is not included in active management of the third stage of labor?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.Which of the following is not an established major risk factor for osteoporosis?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.Which of the following is not an associated risk factor for osteoporosis?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.What is the most common presenting fracture in osteoporosis?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.Which of the following sites for osteoporotic fracture is most commonly associated with morbidity and mortality?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.Which of the following conditions is not associated with an increased risk for osteoporosis?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.Which of the following is not a therapy approved by the Food and Drug Administration (FDA) for the prevention of osteoporosis?

A 61-year-old postmenopausal female comes to your office for a routine health exam. She has a history of osteoarthritis, and she smokes one pack of cigarettes per day. She fractured her left wrist at age 50 years after falling down some stairs. Her mother has osteoporosis and fractured her hip after a fall. Her diet is low in calcium-rich foods, and she is not currently taking a calcium supplement. She is on no medications. Her blood pressure is 120/80 mmHg, her height is 160cm, and she weighs 52kg. The rest of her physical exam is normal.Which of the following statements regarding non-pharmacologic management for the prevention and treatment of postmenopausal osteoporosis is true?

A 41-year-old female comes to your office after finding a breast lump during a routine self-examination. She has been examining her breasts regularly for the past 5 years; this is the first lump she has found. On examination, there is a lump located in the right breast. The lump’s anatomic location is in the upper outer quadrant. It is approximately 3 cm in diameter and is not fixed to skin or muscle. It has a hard consistency. There are three axillary nodes present on the right side; each node is approximately 1 cm in diameter. No lymph nodes are present on the left.At this time, what would you do?

A 41-year-old female comes to your office after finding a breast lump during a routine self-examination. She has been examining her breasts regularly for the past 5 years; this is the first lump she has found. On examination, there is a lump located in the right breast. The lump’s anatomic location is in the upper outer quadrant. It is approximately 3 cm in diameter and is not fixed to skin or muscle. It has a hard consistency. There are three axillary nodes present on the right side; each node is approximately 1 cm in diameter. No lymph nodes are present on the left.What is the first diagnostic procedure that should be performed in this patient?

A 41-year-old female comes to your office after finding a breast lump during a routine self-examination. She has been examining her breasts regularly for the past 5 years; this is the first lump she has found. On examination, there is a lump located in the right breast. The lump’s anatomic location is in the upper outer quadrant. It is approximately 3 cm in diameter and is not fixed to skin or muscle. It has a hard consistency. There are three axillary nodes present on the right side; each node is approximately 1 cm in diameter. No lymph nodes are present on the left.What is the definitive procedure that should be performed in this patient?

A Female with a Suspicious Lesion Discovered on Mammography A mammographic examination uncovered a very suspicious lesion in the right breast of a 49-year-old female. Clinically, the lesion is a 3-cm mass present in the left upper outer quadrant. No axillary lymph nodes are palpable. You refer her to a surgeon who books her for a surgical procedure. What surgical procedure should be used in this patient?

A Female with a Suspicious Lesion Discovered on Mammography A mammographic examination uncovered a very suspicious lesion in the right breast of a 49-year-old female. Clinically, the lesion is a 3-cm mass present in the left upper outer quadrant. No axillary lymph nodes are palpable. You refer her to a surgeon who books her for a surgical procedure.The risk factors for carcinoma of the breast include which of the following?

A Painful Bilateral Breast Masses That Wax and Wane with Her Period A 42-year-old female comes to your office with bilateral breast masses that are painful and seem to “come and go” depending on the stage of the menstrual cycle. There is significant pain with these masses during menstruation. On examination, there are two areas of dense tissue, one in each breast, and each is approximately 4 cm in diameter. No axillary lymph nodes are palpable.What is the most likely diagnosis in this patient?

A Painful Bilateral Breast Masses That Wax and Wane with Her Period A 42-year-old female comes to your office with bilateral breast masses that are painful and seem to “come and go” depending on the stage of the menstrual cycle. There is significant pain with these masses during menstruation. On examination, there are two areas of dense tissue, one in each breast, and each is approximately 4 cm in diameter. No axillary lymph nodes are palpable.If medical treatment is indicated and prescribed for the condition described here, which of the following should be considered as the therapeutic agent of first choice?

A 23-year-old female consults her physician because of a breast mass; the mass is mobile, firm, and approximately 1 cm in diameter. It is located in the upper outer quadrant of the right breast. No axillary lymph nodes are present.What is the most likely diagnosis in this patient?

A 23-year-old female consults her physician because of a breast mass; the mass is mobile, firm, and approximately 1 cm in diameter. It is located in the upper outer quadrant of the right breast. No axillary lymph nodes are present.What is the treatment of choice for the condition described here?

A 33-year-old female comes to your office with a 2-month history of a bloody unilateral left nipple discharge. She also has noted a small and soft lump just beneath the areola on the left side. On examination, there is a 4-mm soft mass located just inferior to the left areola. No other abnormalities are present in either breast. What is the most likely diagnosis in this patient?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.What is the most likely diagnosis in this patient?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.You treat the patient accordingly and her symptoms resolve. She returns 6 months later for her routine Pap smear. The Pap smear results return as “satisfactory for evaluation, negative for intraepithelial lesion or malignancy, fungal organisms morphologically consistent with Candida species.” The patient is asymptomatic, and speculum and pelvic examination are normal. What is the next most appropriate step?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.Which of the following has not been shown to increase the risk for recurrence of this condition?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.Which of the following is an appropriate treatment for this patient?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.This patient returns 2 weeks later stating that she has not responded to the treatment you prescribed. What should you do next?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.Which of the following is not included in the classification for uncomplicated vulvovaginal candidiasis as defined by the Centers for Disease Control and Prevention (CDC)?

A 21-year-old woman comes to your office complaining of severe vulvo-vaginal itching and discharge. She just finished a course of antibiotics for an uncomplicated urinary tract infection, and she states that her urinary symptoms have resolved. She has been sexually active with the same male partner for more than a year. They use latex condoms, and she has been taking oral contraceptive pills for the past 3 months. She has no medical problems or history of sexually transmitted infections (STIs). Her annual Papanicolaou (Pap) tests have all been normal. On inspection of the external genitalia, you note vulvar erythema, fissures, and swelling. On speculum examination, you note a thick, white, curdy discharge adherent to the vaginal walls with no odor. She has no vulvovaginal or cervical lesions. You perform a gross and microscopic examination of the vaginal discharge. The vaginal pH is 4, the whiff test is negative, the wet mount (saline-prepped slide) reveals no evidence of clue cells or trichomonads, and the KOH prepped slide reveals several pseudohyphae.Which of the following statements regarding prophylactic antifungal therapy for recurrent VVC is true?

A 29-year-old woman comes to your office with a 2-week history of a persistent, malodorous vaginal discharge. The unpleasant “fishy” odor appears to worsen after sex. She denies any vaginal itching, urinary symptoms, or any other complaints. She is in a long-standing monogamous relationship with her husband, who is asymptomatic. She has no history of sexually transmitted diseases (STDs) or abnormal Pap test results. She has been douching weekly for the past several months. On examination, there is a thin, milky, off-white discharge present at the introitus without any evidence of vulvar irritation. On speculum examination, the discharge is homogeneous and pooling on the floor of the vagina with no signs of vaginal or cervical inflammation. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is strongly positive, the wet mount slide reveals the presence of several clue cells but no trichomonads or polymorphonuclear/white blood cells (WBCs), and the KOH slide reveals no evidence of pseudohyphae or budding yeast cells. What is the most likely diagnosis in this patient?

A 29-year-old woman comes to your office with a 2-week history of a persistent, malodorous vaginal discharge. The unpleasant “fishy” odor appears to worsen after sex. She denies any vaginal itching, urinary symptoms, or any other complaints. She is in a long-standing monogamous relationship with her husband, who is asymptomatic. She has no history of sexually transmitted diseases (STDs) or abnormal Pap test results. She has been douching weekly for the past several months. On examination, there is a thin, milky, off-white discharge present at the introitus without any evidence of vulvar irritation. On speculum examination, the discharge is homogeneous and pooling on the floor of the vagina with no signs of vaginal or cervical inflammation. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is strongly positive, the wet mount slide reveals the presence of several clue cells but no trichomonads or polymorphonuclear/white blood cells (WBCs), and the KOH slide reveals no evidence of pseudohyphae or budding yeast cells.Which of the following statements regarding this patient’s condition is (are) true?

A 29-year-old woman comes to your office with a 2-week history of a persistent, malodorous vaginal discharge. The unpleasant “fishy” odor appears to worsen after sex. She denies any vaginal itching, urinary symptoms, or any other complaints. She is in a long-standing monogamous relationship with her husband, who is asymptomatic. She has no history of sexually transmitted diseases (STDs) or abnormal Pap test results. She has been douching weekly for the past several months. On examination, there is a thin, milky, off-white discharge present at the introitus without any evidence of vulvar irritation. On speculum examination, the discharge is homogeneous and pooling on the floor of the vagina with no signs of vaginal or cervical inflammation. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is strongly positive, the wet mount slide reveals the presence of several clue cells but no trichomonads or polymorphonuclear/white blood cells (WBCs), and the KOH slide reveals no evidence of pseudohyphae or budding yeast cells.Which of the following is no longer an acceptable treatment for this patient’s condition, according to the CDC?

A 29-year-old woman comes to your office with a 2-week history of a persistent, malodorous vaginal discharge. The unpleasant “fishy” odor appears to worsen after sex. She denies any vaginal itching, urinary symptoms, or any other complaints. She is in a long-standing monogamous relationship with her husband, who is asymptomatic. She has no history of sexually transmitted diseases (STDs) or abnormal Pap test results. She has been douching weekly for the past several months. On examination, there is a thin, milky, off-white discharge present at the introitus without any evidence of vulvar irritation. On speculum examination, the discharge is homogeneous and pooling on the floor of the vagina with no signs of vaginal or cervical inflammation. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is strongly positive, the wet mount slide reveals the presence of several clue cells but no trichomonads or polymorphonuclear/white blood cells (WBCs), and the KOH slide reveals no evidence of pseudohyphae or budding yeast cells.What is the most common class of organisms associated with this patient’s condition?

A 29-year-old woman comes to your office with a 2-week history of a persistent, malodorous vaginal discharge. The unpleasant “fishy” odor appears to worsen after sex. She denies any vaginal itching, urinary symptoms, or any other complaints. She is in a long-standing monogamous relationship with her husband, who is asymptomatic. She has no history of sexually transmitted diseases (STDs) or abnormal Pap test results. She has been douching weekly for the past several months. On examination, there is a thin, milky, off-white discharge present at the introitus without any evidence of vulvar irritation. On speculum examination, the discharge is homogeneous and pooling on the floor of the vagina with no signs of vaginal or cervical inflammation. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is strongly positive, the wet mount slide reveals the presence of several clue cells but no trichomonads or polymorphonuclear/white blood cells (WBCs), and the KOH slide reveals no evidence of pseudohyphae or budding yeast cells.Treatment for BV is indicated for all of the following patients except

A 17-year-old woman comes to your office with her partner complaining of severe vaginal itching and malodorous discharge. She denies any vaginal bleeding or urinary symptoms. She has been sexually active with a new partner for the past 3 months. On external genital examination, you note vulvar edema and erythema. Speculum examination reveals copious, frothy, yellow-green, malodorous discharge with petechial-like lesions on the cervix. A bimanual examination reveals no cervical motion tenderness and no uterine or adnexal masses or tenderness. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is slightly positive, the wet mount reveals several motile flagellated organisms and many WBCs (>10/HPF) but no clue cells, and there are no pseudohyphae or budding yeast cells noted on the KOH slide.What is the most likely diagnosis in this patient?

A 17-year-old woman comes to your office with her partner complaining of severe vaginal itching and malodorous discharge. She denies any vaginal bleeding or urinary symptoms. She has been sexually active with a new partner for the past 3 months. On external genital examination, you note vulvar edema and erythema. Speculum examination reveals copious, frothy, yellow-green, malodorous discharge with petechial-like lesions on the cervix. A bimanual examination reveals no cervical motion tenderness and no uterine or adnexal masses or tenderness. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is slightly positive, the wet mount reveals several motile flagellated organisms and many WBCs (>10/HPF) but no clue cells, and there are no pseudohyphae or budding yeast cells noted on the KOH slide.All of the following statements are true regarding the patient’s condition except

A 17-year-old woman comes to your office with her partner complaining of severe vaginal itching and malodorous discharge. She denies any vaginal bleeding or urinary symptoms. She has been sexually active with a new partner for the past 3 months. On external genital examination, you note vulvar edema and erythema. Speculum examination reveals copious, frothy, yellow-green, malodorous discharge with petechial-like lesions on the cervix. A bimanual examination reveals no cervical motion tenderness and no uterine or adnexal masses or tenderness. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is slightly positive, the wet mount reveals several motile flagellated organisms and many WBCs (>10/HPF) but no clue cells, and there are no pseudohyphae or budding yeast cells noted on the KOH slide.All of the following are acceptable treatments for her condition except

A 17-year-old woman comes to your office with her partner complaining of severe vaginal itching and malodorous discharge. She denies any vaginal bleeding or urinary symptoms. She has been sexually active with a new partner for the past 3 months. On external genital examination, you note vulvar edema and erythema. Speculum examination reveals copious, frothy, yellow-green, malodorous discharge with petechial-like lesions on the cervix. A bimanual examination reveals no cervical motion tenderness and no uterine or adnexal masses or tenderness. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is slightly positive, the wet mount reveals several motile flagellated organisms and many WBCs (>10/HPF) but no clue cells, and there are no pseudohyphae or budding yeast cells noted on the KOH slide.Which of the following recommendations should you give her at this time?

A 17-year-old woman comes to your office with her partner complaining of severe vaginal itching and malodorous discharge. She denies any vaginal bleeding or urinary symptoms. She has been sexually active with a new partner for the past 3 months. On external genital examination, you note vulvar edema and erythema. Speculum examination reveals copious, frothy, yellow-green, malodorous discharge with petechial-like lesions on the cervix. A bimanual examination reveals no cervical motion tenderness and no uterine or adnexal masses or tenderness. You perform a gross and microscopic examination of the vaginal discharge: The pH is 6, the whiff test is slightly positive, the wet mount reveals several motile flagellated organisms and many WBCs (>10/HPF) but no clue cells, and there are no pseudohyphae or budding yeast cells noted on the KOH slide.Which of the following are potential noninfectious causes of vulvovaginitis?

A Female with an “ASC-US” Pap Test Result. A 26-year-old woman comes to your office for her health maintenance examination. She is married with two children, and she has no major medical illnesses. She reports a 10 pack-year history of cigarette smoking. She has had 10 heterosexual partners in her lifetime and denies a history of sexually transmitted disease (STD). All of her Papanicolaou (Pap) tests have been normal. Her physical examination, including pelvic, is unremarkable. A week later, you receive her Pap result, which reads “satisfactory for evaluation, ASC-US.”Which of the following would be appropriate as initial management for this patient?

A Female with an “ASC-US” Pap Test Result. A 26-year-old woman comes to your office for her health maintenance examination. She is married with two children, and she has no major medical illnesses. She reports a 10 pack-year history of cigarette smoking. She has had 10 heterosexual partners in her lifetime and denies a history of sexually transmitted disease (STD). All of her Papanicolaou (Pap) tests have been normal. Her physical examination, including pelvic, is unremarkable. A week later, you receive her Pap result, which reads “satisfactory for evaluation, ASC-US.”All of the following are known risk factors for carcinoma of the cervix except

A Female with an “ASC-US” Pap Test Result. A 26-year-old woman comes to your office for her health maintenance examination. She is married with two children, and she has no major medical illnesses. She reports a 10 pack-year history of cigarette smoking. She has had 10 heterosexual partners in her lifetime and denies a history of sexually transmitted disease (STD). All of her Papanicolaou (Pap) tests have been normal. Her physical examination, including pelvic, is unremarkable. A week later, you receive her Pap result, which reads “satisfactory for evaluation, ASC-US.”What is the most appropriate approach to a patient who undergoes cervical cancer screening with liquid-based cytology and the Pap returns as “satisfactory for evaluation, ASC-US, positive for high-risk HPV type”?

A Female with an “ASC-US” Pap Test Result. A 26-year-old woman comes to your office for her health maintenance examination. She is married with two children, and she has no major medical illnesses. She reports a 10 pack-year history of cigarette smoking. She has had 10 heterosexual partners in her lifetime and denies a history of sexually transmitted disease (STD). All of her Papanicolaou (Pap) tests have been normal. Her physical examination, including pelvic, is unremarkable. A week later, you receive her Pap result, which reads “satisfactory for evaluation, ASC-US.”Carcinoma of the cervix is associated with which HPV types?

A Female with an “ASC-US” Pap Test Result. A 26-year-old woman comes to your office for her health maintenance examination. She is married with two children, and she has no major medical illnesses. She reports a 10 pack-year history of cigarette smoking. She has had 10 heterosexual partners in her lifetime and denies a history of sexually transmitted disease (STD). All of her Papanicolaou (Pap) tests have been normal. Her physical examination, including pelvic, is unremarkable. A week later, you receive her Pap result, which reads “satisfactory for evaluation, ASC-US.”Which of the following statements is true?

A Female with an “ASC-US” Pap Test Result. A 26-year-old woman comes to your office for her health maintenance examination. She is married with two children, and she has no major medical illnesses. She reports a 10 pack-year history of cigarette smoking. She has had 10 heterosexual partners in her lifetime and denies a history of sexually transmitted disease (STD). All of her Papanicolaou (Pap) tests have been normal. Her physical examination, including pelvic, is unremarkable. A week later, you receive her Pap result, which reads “satisfactory for evaluation, ASC-US.”Your colleague asks your opinion about liquidbased cytology for cervical cancer screening. You explain that advantages of liquid-based cytology include