APGO Part 1

A 26-year-old Black G1P0 woman presents to your office at seven weeks gestation with her husband, who is also Black. The patient's brother has sickle cell anemia, and has been hospitalized on numerous occasions with painful crises requiring narcotic pain medication and blood transfusions. What are the odds that this couple will have a child with sickle cell anemia, if the carrier rate for sickle cell disease in the Black population is 1/10?

1 in 60

Objective 03: Cervical Cancer and Sexually Transmitted Infection Screening (2019)

Objective 03: Cervical Cancer and Sexually Transmitted Infection Screening (2019)

Objective 06: Legal Issues & Ethics in Obstetrics and Gynecology (2018)

Objective 06: Legal Issues & Ethics in Obstetrics and Gynecology (2018)

Objective 07: Preventive Care and Health Management (2018)

Objective 07: Preventive Care and Health Management (2018)

Objective 09: Preconception Care (2019)

Objective 09: Preconception Care (2019)

Objective 10: Antepartum Care (2019)

Objective 10: Antepartum Care (2019)

Objective 11: Intrapartum Care (2019)

Objective 11: Intrapartum Care (2019)

Objective 12: Immediate Care of the Newborn (2019)

Objective 12: Immediate Care of the Newborn (2019)

Objective 13: Postpartum Care (2019)

Objective 13: Postpartum Care (2019)

An 18-year-old female presents to the clinic requesting a sports pre-authorization physical. She is the star on the track team for the 400 meter race. She has been in a 2 year relationship with a 20 year old and they frequently use condoms. During your interview he texts her repeatedly wanting to know when she will be done. Her physical examination reveals a thin, nervous, and anxious female with multiple bruises on her arms and legs in various stages of healing. Her vital signs reveal a BP of 104/ 60 and RR 16. You question her about the bruises and she replies that "she is clumsy and falls frequently" during her track practices. What is the next best step in the management of this patient?

Refer to social worker

An 18-year-old G1P0 Asian woman presents with increased fatigue. Her prepregnancy weight was 120 pounds. Her prenatal care has been uncomplicated. Initial hemoglobin at the first visit at eight weeks gestation was 11.1 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a leukocyte count 9,700/mcL, hemoglobin 10.6 g/dL ,mean corpuscular volume (MCV) 88.2 um3 (80.8- 96.4), and platelet count 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient's anemia?

Relative hemodilution of pregnancy

A 26-year-old G2P1 woman at 26 weeks gestation presents for her routine OB followup. She has gained 35 pounds from her nonpregnant weight. Her BMI is 35 kg/m2. She states she is "eating for two." What is the most appropriate next step in counselling of this patient?

She should focus on only gaining 0.5 lbs/week

A 34-year-old G4P4 woman presents with a fever three days after a cesarean delivery. On examination, her incision is healing well, and she has notable fundal tenderness. Which of the following is the most likely cause of her symptoms?

aerobic and anaerobic bacteria

At one minute of life, a newborn infant has a heart rate greater than 120 beats/minute, is crying, has acrocyanosis, gags when suctioned and is vigorously moving all four extremities. What is the Apgar score for this infant?

9

A 30-year-old G0 woman presents with her husband for preconception counseling. The patient is of Ashkenazi Jewish descent. Her husband is Irish. Which of the following genetic diseases is the most likely to affect their future children?

Cystic fibrosis

Objective 08: Maternal-Fetal Physiology (2019)

Objective 08: Maternal-Fetal Physiology (2019)

A 24-year-old G0 woman is considering pregnancy in the next year. Her medical history and physical examination are normal. She is unaware of any significant family history. She is vegetarian, exercises regularly and does not smoke or drink alcohol. Which of the following is the next best step in the management of this patient regarding folic acid supplementation?

Prescribe folic acid supplementation

A 30-year-old G1P0 woman with type 1 diabetes mellitus presents at 10 weeks gestation for a routine visit. She smokes a half pack of cigarettes per day. Her hemoglobin A1C level is 9.7. What structural anomaly is the fetus at highest risk of developing?

Cardiac anomalies

A 28-year-old G0 woman presents to the office for a health maintenance examination. She is currently on oral contraceptive pills, but reports a history of irregular menses prior to starting them. Her past medical history is otherwise non-contributory. On physical examination, she is 5 feet, 2 inches tall, weighs 180 pounds and has a BMI of 33. She has an area of velvety, hyperpigmented skin on the back of her neck and under her arms. What is the next best step in the management of this patient?

Diabetes screen

A 17-year-old G1P1 female delivered a term infant two days ago. She is not interested in breastfeeding and is experiencing painful breast engorgement. She asks for something to suppress lactation. Which of the following is the safest method of lactation suppression in this patient?

Breast binding, ice packs, and analgesics

A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty breathing, cough, and frothy sputum. She was admitted for preterm labor 24 hours ago. She is a nonsmoker. She has received 6 liters of Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: temperature ,98.6°F (37°C), respiratory rate 24/minute, pulse 110 beats/minute, blood pressure 132/85, pulse oximetry is 97% on a nonrebreather mask. She appears in distress. Lung exam reveals bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show leukocyte count 12,000/mm3. Potassium and sodium are normal. Which of the following is the next best step in management?

Administer 20mg Lasix IV

A 35-year-old G4P3 woman comes in for a postpartum visit. She had an uncomplicated vaginal delivery two weeks ago. She has a history of postpartum depression which required treatment with antidepressants after her last pregnancy. Which of the following signs or symptoms is most useful to make a correct diagnosis in this patient?

Ambivalence toward the newborn

A 32-year-old G1 woman with an in vitro fertilization (IVF) conceived pregnancy at 12 weeks gestation has a slightly increased fetal nuchal translucency (3.0 mm), but her first trimester screen shows no increased risk for Down syndrome or Trisomy 18. Still concerned about the increased nuchal translucency, the patient requests additional testing to definitively exclude chromosomal abnormalities. Which of the following is the next best step in the management of this patient?

Amniocentesis

A 16-year-old G1P0 female at 39 weeks gestation presents to labor and delivery reporting a gush of blood-tinged fluid approximately five hours ago and onset of uterine contractions shortly thereafter. She reports that contractions have become stronger and closer together over the past hour. The fetal heart rate tracing is Category I. Uterine contractions are recorded every two to three minutes. A pelvic exam reveals that the cervix is 4 cm dilated and 100 percent effaced. Fetal station is 0. After walking around for 30 minutes, the patient is put back in bed after complaining of further discomfort. She requests an epidural. However, obtaining the fetal heart rate externally has become difficult because the patient cannot lie still. What is the most appropriate next step in the management of this patient?

Apply a fetal scalp electrode

A 28-year-old G2P2 presents for a six-week postpartum check following an unremarkable vaginal delivery of a 3000 g infant. She had a first-degree laceration that was repaired at the time of delivery. She is breastfeeding her infant. On physical examination, her vital signs are normal. Her uterus is firm and nontender. Vaginal exam reveals a well healed vagina with mild erythema and minimal lochia. She would like to resume intercourse soon, but remembers that after her last baby, she had a lot of pain with intercourse. Which of the following is the most likely cause of dyspareunia in this patient?

Atrophic vaginitis

A 26-year-old G2P1 woman at 26 weeks gestation presents for a routine 50 g glucose challenge test. After receiving a one-hour blood glucose value of 148 mg/dl, the patient has a follow-up 100 g 3-hour oral glucose tolerance test with the following plasma values: fasting 102 mg/dl (normal 95 mg/dl), 1-hour 181 mg/dl (normal 180 mg/dl), 2-hour 162 mg/dl (normal 155 mg/dl), 3-hour 139 mg/dl (normal 140 mg/dl). What is the most appropriate next step in the management of this patient?

Begin a diabetic diet and blood glucose monitoring

A 35-year old G2P1 woman is at 11 weeks gestation. She had a triple screen with her last pregnancy and would like to have aneuploidy screening with the current pregnancy. Which of the following screening tests will provide the highest detection rate for Trisomy 21 for this patient?

Cell-free DNA screen

A 35-year-old G2P1 woman presents for her first prenatal visit at 17 weeks gestation. She is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family, or social history. The patient desires genetic testing for Down syndrome. What is the next best step in the management of this patient?

Cell-free DNA screen

A 20- year-old G0P0 woman presents for her first gynecologic examination. She has recently begun having sexual relations with her boyfriend and they are using condoms for contraception. She has no gynecologic complaints. She is healthy and takes no medications. What is the best next step in management for this patient?

Chlamydia and Gonorrhea test

A 51-year-old G4P4 woman presents for her health maintenance examination. She has not seen a physician for the past two years, as she was caring for her sick husband who passed away two months ago. Her last menstrual period was four years ago, and she denies any bleeding since that time. Her past medical and surgical histories are negative. Her mother was diagnosed with ovarian cancer and died at age 54. Her Pap tests have always been normal. Her last Pap test was two years ago, and it was negative for high-risk HPV types. Her exam is normal. Which of the following is the most appropriate screening test for this patient?

Colonoscopy

A 28-year-old G0 woman has a Pap test that is reported as high-grade squamous intraepithelial lesion (HSIL). She is currently sexually active. She has had six sexual partners and has been in a monogamous relationship with her fiancé for the last year. What is the most appropriate next step in the management of this patient?

Colposcopy

A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and whitish sputum for the last three days. She reports that everyone in the family has been sick. She reports a high fever last night up to 102°F (38.9°C). She denies chest pain. She has a history of asthma with no previous intubations. She uses an albuterol inhaler, although she has not used it this week. Vital signs are: temperature 98.6°F (37°C), respiratory rate 16/minute, pulse 94 beats/minute, blood pressure 114/78, peak expiratory flow rate 430 L/min (baseline documented in the outpatient chart = 425 L/min). On physical examination, pharyngeal mucosa is erythematous and injected. Lungs are clear to auscultation. Leukocyte count 8,700 mcL, arterial blood gases on room air (normal ranges in parentheses): pH 7.44 (7.36-7.44), PO2 103 mm Hg (>100), PCO2 26 mm Hg (28-32), HCO3 19 mm Hg (22-26). Chest xray is normal. What is the correct interpretation of this arterial blood gas?

Compensated respiratory alkalosis

A 17-year-old G1P0 female at 32 weeks gestation complains of right flank pain that is "colicky" in nature and has been present for two weeks. She denies fever, dysuria and hematuria. Physical examination is notable for moderate right costovertebral angle tenderness. Leukocyte count is 8,800/mL, and urine analysis is negative. A renal ultrasound reveals no signs of urinary calculi, but there is moderate (15 mm) right hydronephrosis. Which of the following is responsible for the observed clinical findings in this patient?

Compression by the uterus and right ovarian vein

A 34-year-old G4P2 woman at 18 weeks gestation presents with fatigue and occasional headache. She has a sister with Grave's disease. On physical exam, vital signs are normal. BMI is 27 kg/m2. Thyroid is difficult to palpate due to her body habitus. The remainder of her exam is unremarkable. Thyroid function studies show: What is the next best step in the management of this patient?

Continue routine prenatal care

A 27-year-old G2P2 presents for her annual health maintenance visit. She is in good health and is not taking any medications. Her BMI is 35 kg/m2. She states she is planning for a pregnancy next year. What is the most appropriate next step in counseling of this patient?

Counsel on healthy diet and exercise

A 23-year-old G1P0 woman at 38 weeks gestation with an uncomplicated pregnancy presents to labor and delivery with the complaint of lower abdominal pain and mild nausea for one day. Fetal kick counts are appropriate. Her review of symptoms is otherwise negative. Vital signs are: temperature 98.6°F (37.0°C), blood pressure 100/60, pulse 79 beats/minute, respiratory rate 14/minute, fetal heart tracing is Category I, tocometer shows irregular contractions every 2 to 8 minutes, fundal height 36 cm ,cervix is firm, long, closed and posterior. A repeat cervical exam two hours later is unchanged. A urine dipstick is notable for 1+ glucose with negative ketones. Which of the following is the next best step in management?

Dismiss home with labor precautions

A 28-year-old G1P0 woman is at 15 weeks gestation. Her husband's cousin has moderate intellectual disability. Which of the following would be the most common cause of inherited intellectual disability in this patient's child?

Fragile X syndrome

A 32-year-old G2P1 woman is at 20 weeks gestation. Her prior pregnancy was complicated by postpartum endometritis and her son was diagnosed with early-onset neonatal sepsis due to group B streptococcus. Which of the following management options regarding group B streptococcus is most appropriate for this patient?

Do not perform recto-vaginal cultures and treat with antibiotics during labor

A 16-year-old female has a new boyfriend and comes in to discuss contraception. She is well aware of the importance of preventing sexually transmitted infections and specifically wants to know about prevention of pregnancy. Other than abstinence, the most effective method of birth control in this patient is:

Depot medroxyprogesterone acetate (Depo-Provera)

A 34-year-old G2P1 woman is at 40 weeks gestation. She was admitted to labor and delivery in active labor two hours ago. Her cervix was 4 cm dilated and 100% effaced on admission. Her fetus was vertex and -3 station. You are called to examine the patient after she experiences spontaneous rupture of membranes. The cervix is 9 cm dilated, and the fetal head is occiput anterior (OA) at +1 station. You palpate a 5 cm long section of umbilical cord in the patient's vagina. The fetal heart tracing is Category I. The patient is having regular uterine contractions every two to three minutes. She has an epidural and is not feeling the contractions. What is the most appropriate next step in the management of this patient?

Elevate the fetal head with a vaginal hand and perform a cesarean delivery

A 23-year-old G1P1 woman develops a fever on the third day after an uncomplicated cesarean delivery that was performed secondary to arrest of descent. The only significant finding on physical exam is moderate breast engorgement and mild uterine fundal tenderness. What is the most likely diagnosis of this patient?

Endometritis

A 27-year-old G1P1 woman delivered her first baby two days ago. Her pregnancy and delivery were unremarkable. She is healthy with no major medical problems. She wants to begin postpartum contraception immediately. Which of the following should be avoided in this patient?

Estrogen-progesterone oral contraceptive

A 34-year-old woman presents for her well woman examination and is concerned she may have osteoporosis because of left hip pain. The pain started after a fall while jogging one week ago; it is intermittent and relieved with NSAIDs. Her 63-year-old mother has severe osteoporosis and suffered a hip fracture last year. Patient denies smoking but consumes one to two alcoholic drinks daily. Physical examination reveals a 5-foot, 9-inch woman with a BMI of 30. She has a resolving bruise on her left buttock. What risk factors place her at greatest risk for osteoporosis?

Family History

A 24-year-old G1P1 woman delivered a full term baby boy. He is doing well, his newborn exams are normal, and he has been cleared for discharge home. You are seeing her on postpartum rounds and she is interested in circumcising her son, however her husband is not circumcised and is resistant. What medical information is available to help guide their decision regarding the benefit of circumcision?

Fewer UTIs compared to uncircumcised

A 19-year-old G1P0 woman at 41 weeks gestation, with two prior prenatal visits at 35 weeks and 40 weeks, presents in active labor. Review of available maternal labs shows blood type O+; RPR non-reactive, HBsAg negative, and HIV negative. She delivers a small female infant who cries spontaneously. On examination, you find the infant has a slightly flattened nasal bridge. Her ears are small and slightly rotated. What is the most appropriate next step in the management of this patient?

Further examine the infant for sandal gap toes and hypotonia

A 42-year-old G5P4 woman at eight weeks gestation presents for her first prenatal appointment. She has glycosuria noted on urine dipstick in the office. She has a history of four prior vaginal deliveries at full-term, with birth weights ranging from 9 to 10.5 pounds. Family history is positive for type 2 diabetes in her mother and two siblings. Weight is 265 pounds, and height is 5 feet, 4 inches (BMI is 45.5 kg/m2). Which of the following recommendations concerning weight gain during this pregnancy is most appropriate?

Gain 11-20 pounds

A 25-year-old G6P2 woman in active labor is treated with mepiridine. The patient reports the use of marijuana to control nausea during her pregnancy. She quickly progresses from 4 cm to fully dilated in 1 hour and is now pushing. A limp unresponsive infant is delivered. Heart rate is 90 beats/minute. The infant has no respiratory effort. Which of the following is the most appropriate next step in the management of the neonate?

Give positive pressure ventilation and prepare to intubate

A Black couple comes to you for preconception counseling. Neither one has any significant family or genetic history. Based on their race, which of the following blood tests are recommended?

Hemoglobin electrophoresis and CBC

A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores were initially fluid-filled, but are now open, weeping, and crusted. She reports a fever and is having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical exam, she is in obvious distress. Temperature is 100.2°F (37.9°C), pulse 100 beats/minute. Examination of the genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are localized to the perineum, labia minora, and vestibule. Swelling is diffuse. The lesions are eroded, some with a purulent eschar. There is exquisite tenderness to touch. Which of the following is the next best step to evaluate this patient?

Herpes Culture

A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present for three days. This lesion has occurred twice in the past. She states that herpes culture was done by her doctor during her last outbreak and was negative. She is getting frustrated that she does not know her diagnosis. She has no significant previous medical history. She uses oral contraceptives and condoms. She has had four sexual partners in her lifetime. On physical examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. Which of the following best explains the negative culture?

Herpes cultures have a 10-20% false negative rate

A 27-year-old G1P0 woman at 12 weeks gestation presents for first prenatal care visit. She is healthy and takes no medications. An ultrasound is performed, and a viable pregnancy is confirmed. At the end of the visit, the patient discusses with you her desire to have a cesarean delivery, as she does not wish to go through the pain of labor. Her husband, an orthopedic surgeon, expresses concerns as they desire to have at least three children and he is worried about potential complications with repeated cesarean deliveries. What is the most appropriate next step in the counseling of this patient?

Honor her decision after proper counseling and schedule a cesarean delivery at 39 weeks gestation

A 30-year-old G2P0 woman at 38 weeks gestation has just delivered a male infant. She has a history of type 1 diabetes since age 11. Maternal labs show blood type B+, RPR non-reactive, HBsAg negative, HIV negative, and GBS negative. She had poor control of blood sugar during her pregnancy. For which of the following conditions must the pediatrics team monitor the newborn?

Hypoglycemia

A 30-year-old G2P1 woman at 39 weeks has had an uncomplicated pregnancy. She is admitted to labor and delivery and delivers a vigorous male infant. Following delivery, which of the following would be the most appropriate next step?

Initiate skin to skin contact with mother

A 50-year-old G0 deaf woman presents to the clinic for a well woman examination and she denies problems at this time. She is from Mexico and her entire family is still there. She works part-time as a janitor and currently has no health insurance. Her physical examination is unremarkable and her vital signs reveal a BP of 126/74 and RR 16. You recommend she have a Pap test and a mammogram. What is this patient's greatest obstacle to healthcare access and having these tests?

Lack of healthcare insurance

A 24-year-old G1P0 woman presents in active labor at 39 weeks gestation. She reports leaking fluid for the last two days. She develops a temperature of 102.0°F (38.9°C), and fetal heart rate tracing is Category II with heart rate 180 beats/minute and minimal variability. Maternal labs show blood type O+, RPR non-reactive, HBsAg negative, HIV negative, and GBS unknown. What will be the expected appearance of the baby at delivery?

Lethargic, pale with high temperature

A 40-year-old G2P2 woman presents for her first health maintenance examination. She denies any new complaints or symptoms. She has no history of any gynecologic problems. Family history is significant for a father with hypertension and a mother, deceased, with breast cancer diagnosed at age 56. A paternal aunt has ovarian cancer, which was diagnosed at age 83. A physical exam is unremarkable and breast are slightly dense. What screening test should be offered to this patient next?

Mammogram

Mary is a 65-year-old G2P2 woman with lung metastases from cervical cancer. She was recently weaned from mechanical ventilation after being on the ventilator for four weeks. She has a tracheostomy. Mary currently has worsening pulmonary function and needs to go back on the ventilator or she will die within a few days. Mary's husband, Jim, has power of attorney for Mary's health care decisions. The attending offers Mary a choice of either no ventilation with morphine for comfort or resumption of mechanical ventilation. Mary decides she prefers to go back on the ventilator. Jim prefers that she does not go back on the ventilator because the doctor has said that Mary may never wean off of the ventilator again. Who should make the decision about whether to put Mary back on the ventilator?

Mary

A 36-year-old G0 woman who is a health care worker presents for a health maintenance examination. She is sexually active and not using contraception. She doubts she is pregnant, but would be happy if she were. As part of her general preventive care, you discuss immunizations. Which vaccination is contraindicated if this patient gets pregnant now?

Measles-Mumps-Rubella (MMR)

A 38-year-old G0 woman comes to the office because she noted a persistent yellow, frothy discharge associated with mild external vulvar irritation. She denies any odor. She tried over-the-counter anti-fungal medication without success. The discharge has been present for more than three months, gradually increasing in amount. Douching has resulted in temporary relief, but the symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix. A sample of the discharge is examined under the microscope. Which of the following would be the most likely finding?

Motile ovoid protozoa with flagella

A 20-year-old G1P0 woman at 18 weeks gestation with a history of epilepsy has conceived while taking valproic acid. She is scheduled for an ultrasound. Which of the following is the most likely congenital defect associated with prenatal exposure to valproic acid?

Neural tube defects

A 24-year-old G0 woman presents to you for preconception counseling. Her medical history is notable for type 1 diabetes mellitus, hypertension, epilepsy, and hypothyroidism. Her medications include insulin, labetalol, valproic acid, and levothyroxine. Based on her medication exposure, her infant is at greatest risk for which of the following anatomical defects?

Neural tube defects

A 27-year-old G1P0 woman at 34 weeks gestation is brought in by ambulance after a motor vehicle accident. Although restrained in the car with a safety belt, she suffers a significant head laceration and is accompanied by her friend. When she arrives in the emergency department, her initial trauma survey is completed and she has bright red blood coming from the vagina. Her abdomen is noted to be tense. Subsequent documentation of the fetal heart tones reveals fetal tachycardia. Abruption is suspected, and the patient is rushed to the operating room for an emergent cesarean delivery. After delivery, the nurse notes that an informed surgical consent was never signed. What is the most appropriate next step regarding patient consent for treatment?

No need to obtain written informed consent in emergency situation if a delay in treatment would risk the patients health/life

A 38-year-old G1P0 woman is admitted at 42 weeks gestation with an anencephalic infant for induction of labor. The attending physician recommended not to monitor the baby's heart rate during labor because he would not intervene with a cesarean delivery in the event of fetal distress or demise. The physician's action is justified by which one of the following concepts?

Non-maleficence to the patient

A 42-year-old G5P4 woman at eight weeks gestation presents for her first prenatal appointment. She has glycosuria noted on urine dipstick in the office. She denies urinary frequency and urgency. The remainder of the dipstick is normal. Which of the following is the most likely diagnosis?

Normal pregnancy

A 35-year-old G3P2 woman presents for her initial prenatal care visit at 15 weeks gestation, according to her last menstrual period. She reports that a home pregnancy test was positive five weeks ago. Review of her history is unremarkable, and her entire family is in good health. Physical examination reveals a 10-week size uterus. Which of the following is the most appropriate next step in establishing this pregnancy's Gestational age?

Obstetric ultrasound

A 39-year-old G0 woman presents to the clinic reporting non-tender lesions on her vulva for one week. She denies pruritus or pain. She has a brownish rash on the palms of her hands. She endorses IV drug abuse. She was diagnosed as HIV-positive two years ago, but she has not been compliant with suggested treatment. On examination, three elevated plaques with rolled edges are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her hands and the soles of her feet. What is the most appropriate next step in the management of this patient?

Obtain a treponomal specific test

A 26-year-old G2P1 woman at 41 weeks gestation is brought in by ambulance. The emergency medical technician reports that a pelvic examination performed 20 minutes ago when the patient had a severe urge to push revealed that she was fully dilated and the fetal station was +2. Fetal heart tones were confirmed to be 150 beats/minute with no audible decelerations. When the patient is placed on the fetal monitor, the heart rate is noted to be 60 beats/minute. The maternal heart rate is recorded as 100 beats/minute. Without pushing, the fetal scalp is visible at the introitus. A repeat pelvic exam shows that the fetus is in the occiput anterior position. Which of the following is the most appropriate next step in the management of this patient?

Operative vaginal delivery

A 45-year-old G2P2 woman presents for a six-week postpartum check. She reports crying spells, loss of appetite, difficulty sleeping and a feeling of low self-worth that began one week after her delivery. She denies any suicidal or homicidal ideations. She is frustrated because she has not been able to breastfeed and feels that she is a bad mother. She has a previous history of anxiety. Which of the following is the most likely diagnosis in this patient?

Postpartum depression

A 23-year-old G1P1 woman delivered a healthy infant two days ago. She has had difficulty breastfeeding despite multiple attempts. Her nipples are sore and cracked and she is thinking about exclusively bottlefeeding. Her pregnancy was complicated by gestational diabetes, chronic hypertension and a history of an abnormal Pap test. She had a cone biopsy two years ago and had a normal Pap test with the current pregnancy. The patient's mother has a history of endometrial and colon cancer and her maternal grandmother and grandfather both had fatal heart attacks in their early 60s. Breastfeeding decreases the risk of which of the following for this patient?

Ovarian cancer

A 22-year-old G2P1 woman was admitted to labor and delivery with a cervical exam of 6 cm dilated and 90% effaced. Four hours later she is 7 cm dilated and 90% effaced. On external tocometer, she is having painful contractions every two to three minutes. The fetal heart rate tracing is Category I. Which of the following is the most appropriate next step in management?

Placement of an intrauterine pressure catheter

A 19-year-old G0 woman presents with lower abdominal cramping. The pain started with her menses and has persisted, despite resolution of the bleeding. She thinks she may have a fever but has not taken her temperature. No urinary frequency or dysuria are present. Her bowel habits are regular. She denies vomiting but has mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives, and states that her partner does not like condoms. On examination: temperature is 100.2°F (37.9°C), pulse 90 beats/minute, blood pressure 110/60. She is well-developed and nourished and in mild distress. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable with yellow discharge at the os. Cervical motion tenderness is present. The uterus and the adnexa are tender without masses. Urine dip is negative for nitrates. Urine pregnancy test is negative. What is the most likely diagnosis?

PID

A 32-year-old G2P2 woman presents for a health maintenance examination. She is in good health and takes no medications. She does not have a history of abnormal Pap tests, and her last one was three years ago. Her examination is normal, including her pelvic exam. A Pap test is performed and returns as normal with high-risk HPV negative. What is the most appropriate screening recommendation for cervical cancer in this patient?

Pap and HPV testing in 5 years

A 25-year-old G3P2 woman, who had recently undergone a primary cesarean delivery, had her HIV status revealed to her mother when a nurse left her chart open in the recovery room. She speaks to patient relations and is thinking about seeking damages through legal avenues. When trying to explain the concept of patient privacy, which of the following statements is correct?

Patient privacy is the responsibility of all health care providers who may be fined and/or assessed criminal penalties for violating the privacy of the patient protected health information

You are asked to give a lecture on a new chemotherapy drug that has demonstrated a reasonable efficacy in women with advanced cervical cancer. The day before giving the lecture, you realize that you own stock in the company that makes the drug. Which of the following statements about conflict of interest is true?

Pharmaceutical companies can support the cost of medical conferences in which physicians receive continuing medical education credits

A 34-year-old G3P1 woman at 26 weeks gestation reports "difficulty catching her breath," especially after exertion for the last two months. She is a non-smoker. She does not have any history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64, pulse 88 beats/minute, respiratory rate 15/minute, and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman's symptoms?

Physiologic dyspnea of pregnancy

A 23-year-old G1P0 at 39 weeks gestation presents in spontaneous labor. Pregnancy was complicated by gestational diabetes. She delivers a 4200 g infant with ruddy color and jitteriness. The infant is at immediate risk for which of the following conditions?

Polycythemia

A 21-year-old G1P0 woman delivered a 4000 g infant by a low-forceps delivery after a prolonged labor course that included a three-hour second stage. Her prenatal course was notable for anemia, poor weight gain and maternal obesity. Following the delivery, she required extensive repair of a vaginal sulcus laceration and a seconddegree perineal laceration. Her hematocrit was 30% on postpartum day one. Which of the following factors places this patient at greatest risk for developing a puerperal infection?

Prolonged labor

A 38-year-old G3P3 woman presents to the office for a health maintenance examination. Her past medical history is negative. Her family history is significant for hypertension in her father and diabetes mellitus in her mother. Her grandfather passed away from colon cancer at the age of 82. She is worried about getting colon cancer and desires to undergo screening. Her body mass index (BMI) is 23 and her physical exam is normal. What is the most appropriate next step in the management of this patient?

Recommend a colonoscopy at age 45-50, and if normal, repeat every 10 years

A 35-year-old woman presents for a preconception consultation. Her medical history is notable for a seizure disorder. She has been well controlled on lamotrigine and she has been seizure free for nine months. Which of the following is the next best step in the management of this patient?

Recommend initiation of folate supplementation

A 24-year-old G0P0 woman presents for a second opinion. She recently had a lowgrade squamous intraepithelial lesion (LSIL) Pap and underwent colposcopy with biopsies showing cervical intraepithelial neoplasia (CIN1). This was her first abnormal Pap test. She is in good health and not taking any medication. Her provider recommended a LEEP. She is actively trying to get pregnant, but is concerned that this diagnosis means she has cancer. What is the best next step in management for this patient?

Repeat cytology in 12 months

A 21-year-old G0 woman returns for followup on her abnormal Pap test, which was atypical squamous cells of undetermined significance (ASCUS). Reflex high-risk HPV testing is positive. Her pelvic exam reveals a normal cervix. What is the next best step in the management of this patient?

Repeat cytology test in 1 year

A 35-year-old G1P0 woman at 32 weeks gestation is hospitalized for glycemic management. Her prenatal course has been complicated by chronic hypertension and type 2 diabetes mellitus. She has been poorly compliant with her diabetes regimen. She reports her insulin regimen as 2 units NPH in the morning. She receives 20 units due to incorrect entry of the order by the intern. She is found two hours later shaky and sweaty in her bathroom by the nurse. Her blood glucose level is 55 mg/dL. She is given appropriate management and recovers without incident. In addition to disclosing the error to the patient, which of the following is the most appropriate next step in management?

Report the incident to risk management

A 25-year-old G3P2 woman delivered a normal female infant with Apgars of 9 at one minute and 9 at five minutes 40 minutes ago. She sustained no lacerations and had no episiotomy. Her placenta has not delivered, despite active management of her third stage. Her EBL is 350cc. Vital signs are temperature 98.6°F (37.0°C) blood pressure 100/60, pulse 79 beats/minute, respiratory rate 14/minute. Which of the following best describes this patient's condition?

Retained placenta

A 28-year-old G1P0 woman at 34 weeks gestation had pulmonary function tests (PFT) performed two days ago because she was feeling slightly short of breath. She is a non-smoker and has no personal or family history of cardiac or respiratory disease. Vital signs are: respiratory rate 16/minute, pulse 90 beats/minute, blood pressure 112/70, temperature 98.6°F (37°C), oxygen saturation is 99% on room air. On physical examination, lungs are clear; abdomen nontender; fundal height is 34 cm. The results of the pulmonary function tests (PFT) are: inspiratory capacity (IC) increased, tidal volume (TV) increased, minute ventilation increased, functional reserve capacity (FRC) decreased, expiratory reserve capacity (ERC) decreased, residual volume (RV) decreased. What is the next best step in the evaluation of this patient?

Routine prenatal care

A 21-year-old G1P1 woman presents with amenorrhea since the birth of her 1-year-old daughter. She reports extreme fatigue, forgetfulness, and depression. She was unable to breastfeed because her milk never came in, and she feels guilty about this. She notes hair loss including under her arms and in her pubic area. Her delivery was complicated by a postpartum hemorrhage and hypovolemic shock, requiring aggressive resuscitation and dilation and curettage. She is afebrile. Vital signs are: blood pressure 90/50, pulse 84 beats/minute. The patient appears tired. Her exam is normal but she is noted to have dry skin. A urine pregnancy test is negative. Which of the following is the most likely diagnosis in this patient?

Sheehan's Syndrome

A 42-year-old G2P2 woman presents for a health maintenance examination. Her past medical history is negative. Her family history is significant for hypertension and hypercholesterolemia in her father and diabetes mellitus in her mother. Her body mass index (BMI) is 23. What lifestyle modification is most important for this patient?

Starting an aerobic exercise program

A 26-year-old G2P1 woman at 27 weeks gestation presents for her routine prenatal appointment. Her past medical history is notable for moderate persistent asthma for which she takes fluticasone, montelukast, and she has an albuterol inhaler for use as needed. She is allergic to cats. The patient has missed her last two appointments due to lack of transportation and has required two visits to the Emergency Department for asthma exacerbations. The patient recently lost her job and needed to move in with her sister. The household consists of three adults, five children, and two cats. Which of the following is the most likely factor contributing to her asthma exacerbations?

The cats

A 32-year-old G3P1 woman at 39 weeks gestation is admitted to labor and delivery for a scheduled repeat cesarean delivery. Maternal labs show HIV positive, blood type B+, RPR non-reactive, HBsAg negative, GBS negative, PPD positive, CXR negative. She received adequate antiretroviral therapy prior to and during the pregnancy. Her viral load was undetectable throughout the second and third trimester. A live male infant is delivered with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. Which of the following is the most appropriate next step in the management of the newborn?

Treat the infant with zidovudine (AZT) immediately after delivery

A 24-year-old G1P0 woman has just delivered 37 week male twins. On your initial assessment, you notice twin A is large and plethoric, and twin B is small and pale. A complete blood count (CBC) is obtained on both twins. You suspect twin-twin transfusion. Which of the following findings would support your theory?

Twin A with polycythemia

A 40-year-old G1 woman comes in for her first prenatal visit. This is an unplanned pregnancy and she had a positive urine pregnancy test a week ago. She is 16 weeks gestation based on her last menstrual period. She elects to have screening for aneuploidy and open neural tube defects. Her cell-free DNA test returns screen negative. Her maternal serum alphafetoprotein (MSAFP) is increased (2.6 MoM). What is the next best step in management of this patient?

Ultrasonic assessment of gestational age

A 29-year-old G2P1 woman at 36 weeks gestation is seen for management of gestational diabetes. Despite diet modification, the patient has required insulin to control her serum glucose levels. She has gained 25 pounds with the pregnancy. Her fundal height is 42. Which of the following would be the next best step in management?

Ultrasound for EFW and AFI

A 35-year-old G0P0 woman at 27 weeks gestation presents to the Emergency Department with flank pain, chills and mild myalgias. Her vital signs are temperature 102.0o F (38.9o C), blood pressure 100/68, pulse 100 beats/minute, respiratory rate 12/minute. On physical examination, her abdomen is soft and nonacute, and she demonstrates right sided costovertebral angle tenderness. Her UA is consistent with UTI. KUB reveals hydronephrosis. Which of the following is most likely to contribute to the development of pyelonephritis in this patient?

Uterine dextrorotation

A 34-year-old G1P0 woman at 39 weeks gestation presents in active labor. Her cervical examination an hour ago was 5 cm dilated, 90 percent effaced and 0 station. She just had spontaneous rupture of membranes and is found to be completely dilated with the fetal head is at +3 station. The fetal heart rate tracing is shown below. What is the most likely etiology for these decelerations?

Uteroplacental insufficiency

A 25-year-old G1 woman presents to labor and delivery with contractions. She is at 40 weeks gestation. Her cervix is 6 cm dilated and 100% effaced. The fetus is in the occiput anterior presentation at +1 station. The fetal heart tracing is Category I. The patient had a fetal ultrasound three days ago which reported an estimated fetal weight (EFW) of 2900 g. The patient's older sister had a forceps-assisted vaginal delivery and has fecal incontinence. The patient would like to avoid having this same complication. Which of the following management plans is most appropriate for this patient?

Vaginal delivery with no episiotomy

A 27-year-old G3P1 woman is admitted to the orthopedic service after open reduction and internal fixation of her femur status post a motor vehicle accident. Her past medical history is significant for diabetes (controlled with metformin) and a history of a deep venous thrombosis three years ago while taking an oral contraceptive. She has been receiving ibuprofen for pain control and oxycodone for breakthrough pain as well as docusate sodium (Colace). Additionally, anticoagulation therapy was begun with IV heparin, and is now therapeutic on warfarin. At a follow-up visit, she has a positive pregnancy test and an ultrasound confirms a six-week intrauterine pregnancy. Which of the following medications should be discontinued now?

Warfarin

A 34-year-old woman presents for her well woman examination and denies problems. Her 63-year-old mother has severe osteoporosis and suffered a hip fracture last year. Patient denies smoking but consumes one to two alcoholic drinks at parties every few months. Physical examination reveals a 5' 9 "tall woman with a BMI of 30. In this patient, what would be the best way to lower her risk of osteoporosis?

Weight bearing exercises 4 times per week

A 72-year-old G3P1 woman has progressive ovarian cancer. She and her husband have already completed a medical power of attorney form. However, the patient did not complete a living will or any other documents expressing her wishes for the initiation of mechanical ventilation or cardioversion in the event of a respiratory or cardiac arrest. Unfortunately, the patient is brought into the hospital after suffering an incapacitating seizure. She is not arousable when she reaches the oncology unit. Her husband, Jim, is present and willing to act as Mary's surrogate decision-maker. When he decides on the proper course of care, the husband should make decisions based primarily on which of the following?

What Mary would have chosen

A 25-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with spontaneous onset of labor and spontaneous rupture of membranes. Her cervical exam was 5 cm dilated, 90 percent effaced, and 0 station at presentation two hours ago. Presently, the patient is uncomfortable and notes strong contractions. The cervical examination is unchanged from admission. You decide to place an intrauterine pressure catheter (IUPC). On placement, approximately 300 cc of frank blood and amniotic fluid flow out of the vagina. What is the most appropriate next step in the management of this patient?

Withdraw the IUPC, monitor the fetus and then replace if tracing is reassuring

A 23-year-old G1P0 woman comes into the office after having some light inter-menstrual spotting and cramping. She is currently sexually active and has had unprotected intercourse with two different partners over the past three months. A urine pregnancy test is positive. She does not desire to keep the pregnancy and, after an ultrasound scan in the office reveals a six-week viable intrauterine pregnancy, the patient asks about an abortion. However, she does not have health insurance. What is the most appropriate next step in the management of this patient?

You provide appropriate counseling about the availability of abortion