Sarah Michelle Qbank- Womens & Mens health

A nurse practitioner is teaching a student how to perform a cervical pap smear. Which of the following statements would be the most appropriate to include in pre-procedure teaching?

"It is critical to obtain an adequate sample with cells from the transformation zone" he pap smear is an important screening tool for cervical cancer. It detects precancerous or cancerous cells of the cervix by collecting cells for cytology or HPV testing. A cervical pap smear is obtained during a speculum exam by using a spatula, brush, or broom to sample both the ectocervix and endocervix. The area known as the transformation zone is the most common place for abnormal cells to develop in the cervix. The transformation zone consists of squamous epithelial cells and endocervical cells. Obtaining an adequate sample from this zone is critical , as otherwise possible precancerous or cancerous cells may be inadvertently missed. The presence or absence of cells from the transformation zone will be noted on the cytology report. Bacterial or candidal infections, patient age, parity, and pregnancy are all factors that may impact the presence of endocervical or transformation zone cells on a specimen.

A 32-year-old woman who is 28 weeks pregnant presents today for her prenatal checkup. She asks if she needs the Tdap vaccine today, as she received it a year and a half ago during her last pregnancy. What is the most appropriate response from the nurse practitioner?

A Tdap booster is recommended in every pregnancy without regard to when the last booster was administered to provide passive immunity to the fetus Infants typically receive their first dose of the DTaP vaccine at 2 months of age. They will need an additional two doses, given at 4 and 6 months of age, to build full immunity. The mother typically receives their Tdap vaccine during the third trimester of pregnancy between weeks 27 and 36 weeks, which is protective for the fetus and newborn.Live vaccinations are contraindicated during pregnancy. These include the varicella vaccine, intranasal influenza vaccine, and measles-mumps-rubella vaccine. Intramuscular influenza is routinely recommended in pregnancy. It is recommended that patients have all other scheduled vaccinations prior to pregnancy, but most vaccinations can be given during pregnancy if applicable.

A 47-year-old woman presents to the clinic with reports of breast leakage for 2 weeks. She is premenopausal and has not experienced breast leakage since she breastfed her last child over 15 years ago. The physical examination is otherwise unremarkable. The nurse practitioner prioritizes galactorrhea on the differential diagnosis. Which of the following tests is not ordered to evaluate for galactorrhea?

A breast ultrasound or mammogram could be used if the breast leakage was suspected to be pathologic in nature, but given the benign physical exam, that is unlikely.Most nipple discharge is physiologic in nature, even in non-lactating patients. Nipple discharge can be stimulated by hormonal influences from progesterone, estrogen, and prolactin. Galactorrhea can be a manifestation of hyperprolactinemia, hypothyroidism, and medications. It is characterized by discharge with compression and multiple-duct involvement. It is also typically bilateral and milky or watery in appearance. If the nipple discharge is spontaneous, bloody, watery, large volume, associated with a single duct, or associated with a mass, it requires further evaluation for pathology.

A 40-year-old woman presents to the office to discuss contraception options. She reports she was recently diagnosed with breast cancer and does not want to become pregnant at this time. Which of the following types of contraception is the most appropriate for the nurse practitioner to recommend to the patient?

A copper intrauterine device (IUD) Hormonal contraception is not recommended for patients with a current breast cancer diagnosis or a history of breast cancer. A copper intrauterine device (IUD) is the most appropriate type of contraception for the nurse practitioner to recommend to this patient, as it is an effective and nonhormonal option. The nurse practitioner should reasonably exclude pregnancy prior to initiating contraception in female patients. Routine Pap smears are advised, as warranted. A copper IUD is inserted at any time during the menstrual cycle and is approved for use for up to 10 years. The efficacy of a copper IUD is comparable to surgical sterilization. It may cause heavier menstrual bleeding and spotting in between periods, so it should not be recommended to patients who experience difficulty with these symptoms.

The nurse practitioner measures a fundal height of 35 cm on a patient who is 37 weeks gestation. What action should the nurse practitioner take in response to this information?

A patient who is 37 weeks gestation should have a fundal height that ranges between 35-39 cm. This is a normal finding, so she should follow up at her next routine prenatal visit as scheduled

A 36-year-old woman presents to the office for a routine physical and gynecological exam. She asks to discuss contraception. Her physical exam is without abnormalities. Which of the following aspects of the patient's history is considered a contraindication to combined oral contraceptive use?

A patient who is currently 18 days postpartum should not be prescribed combined oral contraceptive pills because this is considered a hypercoagulable state and supplemental estrogen intake can increase the risk of blood clots. Safer alternatives for patients < 30 days postpartum are progestin-only pills, medroxyprogesterone acetate (Depo-Provera), or a progestin-only implantable device.Other contraindications for combined oral contraceptive use are: age over 35 and current tobacco use; history of current breast cancer; breast cancer in the last 5 years; history of migraine with aura; personal history of blood clots, hypertension, liver cirrhosis, or diabetic neuropathy; history of stroke; history of lupus; anticonvulsant use; treatment with lamotrigine (Lamictal) and fosamprenavir for HIV pre-exposure prophylaxis.

A 26-year-old man presents with testicular pain, swelling, painful urination, and urinary frequency. Symptoms started 6 days ago and are gradually getting worse. Physical exam reveals testis in the anatomically normal position, left scrotal swelling, warmth, and tenderness. Which of the following findings is most likely to confirm the diagnosis?

A positive Prehn sign occurs when scrotal pain is alleviated with the physical lifting of the testicles, is present in epididymitis but not in testicular torsion. The most common differential diagnoses of acute scrotal pain include epididymitis, testicular torsion, testicular cancer, trauma, inguinal hernia, and torsion of the appendix testis. Acute epididymitis and testicular torsion are the two most common causes of acute scrotal pain in adults Ceftriaxone (Rocephin) 250 mg IM and doxycycline 100 mg orally twice a day for 10 days are the treatment of choice for men between the ages of 14 years and 35 years old. For men over 35 years old that are not at risk for sexually transmitted infections, levofloxacin (Levaquin) 500 mg orally once daily for 10 days is sufficient to treat suspected enteric pathogens.

A 19-year-old patient presents to the clinic with nausea, fatigue, and amenorrhea for 2 weeks. She states that she cannot be pregnant as she has been on birth control and only forgets to take it occasionally. The nurse practitioner decides to run a urine human chorionic gonadotropin pregnancy test, which is positive. The nurse practitioner understands that this is a:

A positive pregnancy test is an example of a probable sign of pregnancy This is considered probable as false positives can occur. Other probable signs of pregnancy include cervical changes or softening of the cervix, mild uterine cramping, or Braxton Hicks contractions.

A 19-year-old patient presents with concerns of milky discharge from both breasts for 2 days. She is extremely worried as her great aunt was recently diagnosed with breast cancer. While the nurse practitioner is aware that this is generally a benign condition, which of the following lab levels would be advisable to check at today's visit?

A prolactin level This patient is exhibiting galactorrhea, which typically presents as bilateral milky nipple discharge involving multiple ducts. Most often, nipple discharge is of benign origin. Galactorrhea can be caused by hyperprolactinemia, so it is advisable to check a prolactin level for this patient. Hyperprolactinemia can occur due to medications such as certain antipsychotics or antidepressants, pituitary tumors, or endocrine abnormalities. If the prolactin level is found to be elevated in the absence of taking a medication known to cause hyperprolactinemia, an MRI of the pituitary gland is warranted along with referral to an endocrinologist.

A 28-year-old woman reports yellow milky nipple discharge from her left breast. She is not currently pregnant, has no history of recent trauma, and gave birth to her only child 7 years ago. A clinical breast exam reveals symmetrical breasts without masses, nodules, inflammation, or lymphadenopathy. The areola is brown with a normal appearance, and a yellowish milky discharge is manually produced bilaterally. What diagnostic test should be ordered for this patient?

A serum prolactin level should be ordered as part of a workup for galactorrhea. Nipple discharge that is unrelated to pregnancy or breastfeeding can be physiologic or pathologic. Galactorrhea is physiologic nipple discharge that is likely to be bilateral, milky or green in color, only present when expressed, and multiductal. But it may also be unilateral with a variety of colors, including yellow, green, and brown. An important distinguishing characteristic is that with galactorrhea, the nipple discharge is never bloody. Galactorrhea is commonly caused by hyperprolactinemia, which may develop secondary to medications, pituitary tumors, endocrine disorders, or other medical conditions. Evaluation of milky nonbloody nipple discharge includes a patient history, a clinical breast exam, and a pregnancy test. If the pregnancy test is negative, a galactorrhea workup should be performed. The initial workup includes a measurement of thyroid-stimulating hormone and serum prolactin levels and a review of the patient's medications to identify medications that are associated with galactorrhea.

Gonorrhea:

A sexually transmitted infection (STI) caused by Neisseria gonorrhoeae and is the most commonly reported STI in the United States. Most patients with gonorrhea are asymptomatic, but if symptoms develop, it occurs within 10 days of contact in women and 2-5 days in men. Clinical manifestations of gonorrhea in women include dysuria, vaginal pruritus, intermenstrual bleeding, mild lower abdominal pain, dyspareunia, and thin, purulent, and mildly odorous leukorrhea. This may progress to pelvic inflammatory disease (PID) in some women. Symptoms of PID include lower abdominal pain, mucopurulent urethral discharge, vaginal discharge, cervical motion tenderness, dysuria, adnexal tenderness, fever, chills, nausea, and vomiting. Clinical manifestations of gonorrhea in men include burning on urination and serous penile discharge that can progress to purulent, blood-tinged discharge. Gonorrhea is treated with antibiotics.

Which of the following assessment findings on a digital rectal exam is consistent with acute bacterial prostatitis?

A tender, warm, and boggy prostate on a digital rectal exam. Acute bacterial prostatitis is most commonly caused by E. coli and other gram-negative bacteria. It causes a variety of localized and systemic symptoms, including fevers, malaise, chills, dysuria, increased urinary frequency, urinary urgency, and pelvic pain. Swelling of the prostate gland can cause issues with bladder emptying. First-line treatment for acute bacterial prostatitis includes an oral fluoroquinolone and trimethoprim-sulfamethoxazole (Bactrim), as these adequately cover gram-negative pathogens.

A 37-year-old man reports dysuria, urinary frequency, painful ejaculation, fever, and malaise. Upon a digital rectal exam, the nurse practitioner notes a tender, warm, enlarged, and boggy prostate. Which of the following is the most likely diagnosis?

A tender, warm, enlarged, and boggy prostate indicates prostatitis Acute prostatitis is an infection of the prostate gland. Patients present with acute onset of dysuria, urinary frequency, urinary urgency, painful ejaculation, hematospermia, or painful defecation. Systemic symptoms such as fever, chills, malaise, myalgia, and nausea are also common. Men may also report pain at the tip of the penis and obstructive urinary symptoms such as a weak stream, hesitancy, and straining to urinate. The physical exam should include an abdominal, genital, and digital rectal exam. The digital rectal exam technique should be gentle since aggressive prostate massage can result in bacteremia and sepsis. The diagnosis is made clinically with a history and physical exam. A urinalysis and urine culture should be obtained in all patients to support the diagnosis and determine effective antibiotic treatment. Empiric antibiotic treatment is based on the suspected mode of infection and presumed organism. The antibiotics can be adjusted based on culture results. Empirical treatment should be started at the time of diagnosis, and the duration of therapy is 10 to 14 days. For patients who are not at risk for sexually transmitted infections, the empiric treatment is ciprofloxacin 500 mg orally every 12 hours, levofloxacin 500 mg orally once daily, or trimethoprim-sulfamethoxazole (Bactrim) orally every 12 hours. Patients younger than 35 years old who are at risk for sexually transmitted infections and patients older than 35 who engage in high-risk sexual behavior should be treated with ceftriaxone (Rocephin) 250 mg IM and doxycycline 100 mg twice a day for 10 days to cover Neisseria gonorrhoeae and Chlamydia trachomatis.

A 30-year-old woman presents with a possible vaginal infection. When looking at the wet mount, the nurse practitioner sees that there is movement on the slide via flagella. What infection does the nurse practitioner believe the patient has based on these wet mount findings?

A wet mount that shows mobile trichomonads that move via flagella is indicative of trichomoniasis Trichomoniasis is a parasitic sexually transmitted infection requiring antibiotic treatment. A common drug used is metronidazole (Flagyl) by mouth or intravaginally. The partner(s) of the infected person also need to be treated.

A pregnant patient is interested in getting the copper T intrauterine device (IUD) for contraception after delivery and would like to learn more information about this method. Which of the following statements is most appropriate to tell the patient?

After delivery, it can be placed within the first 48 hours after birth After that window, a patient should wait until 4-6 weeks postpartum to decrease the risk of expulsion. The IUD is the most commonly used reversible, long-acting contraception method. The copper T IUD is a hormone-free intrauterine device

A woman at 35 weeks gestation presents for her prenatal visit. Her urine dipstick is negative for glucose and protein, and she asks if any other testing will be done at today's visit. Which of the following is the most appropriate response?

All pregnant patients who receive prenatal care between 35 and 37 weeks gestation will be screened for Group B Streptococcus Group B Streptococcus is associated with perinatal UTI, intrauterine infection, preterm delivery, prelabor rupture of membranes, and postpartum infection. A high bacterial load can transfer to the fetus by way of transplacental invasion or vertical transmission during descent through the vaginal canal, and lead to a potentially fatal state of bacterial sepsis.

A 30-year-old woman presents to the clinic with a 6-week history of amenorrhea and believes that she may be pregnant. Which of the following best describes amenorrhea as a sign or symptom of pregnancy?

Amenorrhea is a presumptive symptom of pregnancy because it is a physical sign that suggests a patient of menstruating age may be pregnant, but the pregnancy has not yet been confirmed. Other presumptive symptoms may include changes to the breasts, pigmentary changes to the skin, nausea, urinary frequency, constipation, and fatigue.

A 28-year-old woman at 22 weeks gestation has concerns regarding antibiotic use during pregnancy. She was just diagnosed with strep throat at an urgent care and was prescribed amoxicillin. Which of the following statements is true regarding antibiotic use during pregnancy?

Amoxicillin is a preferred agent to use during pregnancy In addition to amoxicillin, antibiotics from the cephalosporin drug class are also considered safe in pregnancy. If a penicillin allergy is present and there is no history of an IgE-mediated response like anaphylaxis, it is appropriate to prescribe an antibiotic from the cephalosporin drug class.

A pregnant patient at 18 weeks gestation obtains a urine sample as part of a routine prenatal visit. They report no pain or burning with urination, but there are positive leukocytes and nitrites present on the urinalysis. Which of the following reflects the best treatment plan?

Amoxicillin is safe throughout all trimesters of pregnancy and can be used for urinary tract infections as long as the bacteria are susceptible.

A pregnant 34-year-old patient called the clinic today. She was babysitting her nephew this past weekend, and he was diagnosed with erythema infectiosum 2 days later. The patient read online that this can abort her pregnancy, so she is anxious. Which of the following is the appropriate lab test for this patient?

An exposed pregnant patient should be tested for parvovirus B19 antibodies to assess immunity status Fifth disease, or erythema infectiosum, is a common viral illness that is caused by parvovirus B19. Rarely, an acute infection during pregnancy can cause fetal outcomes such as spontaneous abortion, fetal nonimmune hydrops fetalis, and fetal loss. An exposed pregnant patient should be tested for parvovirus B19 antibodies to assess immunity status as soon as possible after exposure. Both B19-specific IgM and IgG should be ordered. IgM reflects recent infection, and IgG indicates past infection and immunity. Pregnant patients exposed to parvovirus B19 should be monitored for potential fetal infection if they are positive for IgM, regardless of the IgG status. Exposed pregnant patients who are negative for IgM and IgG are susceptible to parvovirus B19 infection and should have parvovirus B19 levels repeated in 4 weeks.

The nurse practitioner is starting a 20-year-old patient on ethinyl estradiol and drospirenone (Loryna), a combined oral contraceptive pill. She asks about the side effects she should watch for. Which of the following would be an inappropriate response?

An inappropriate response would be lightening of the skin around the buccal orifice. Combined oral contraceptive pills are not associated with this side effect. Possible side effects of combined oral contraceptives include nausea, breast swelling or tenderness, and bleeding between periods. Oral contraceptives may also trigger melasma, which causes irregular dark patches of skin to develop on the face. Bleeding or spotting between periods during the first few months is a common side effect of oral contraceptive pills. Dark patches of skin on the face may develop due to the estrogen component of the pills. An increase in breast size is another possible side effect.

A 55-year-old woman presents with a chief concern of a small amount of vaginal bleeding and weight gain for the last 2 days. She is thinking a light period has returned but wanted to double check as she has had a lot of vaginal dryness recently. Her last menstrual period was approximately 23 months ago. Which is the most important action for the practitioner to take?

Any episode of postmenopausal bleeding warrants further assessment, so this patient should be promptly referred to gynecology While this patient's bleeding may be due to vaginal atrophy, the main concern is that endometrial cancer may be the cause. Further diagnostic tests would likely include a pelvic ultrasound, an endometrial biopsy, and dilation and curettage to rule out cancer or other pathologies, such as endometrial hyperplasia or polyps. Hyperplasia is considered a precursor to endometrial cancer, while polyps are generally benign.

A 29-year-old patient who is pregnant at 20 weeks of gestation presents to the clinic for a routine prenatal checkup. Which of the following locations is associated with appropriate fetal growth and development at 20 weeks of gestation?

At 20 weeks gestation, the fundal height should be at the level of the umbilicus This can be off by 1-2 cm and still be within normal limits.During pregnancy, the uterus remains in the pelvis until approximately 12 weeks gestation, when it becomes large enough to palpate over the abdomen just above the symphysis pubis. Fundal height measurement is part of a routine prenatal assessment and can assist the nurse practitioner in estimating the due date and detecting fetal growth abnormalities, such as small or large for gestational age. If the fundal height is off by more than 2 cm, the patient should undergo an ultrasound.

A 25-year-old woman presents to the clinic for cervical cancer screening. She last had a Pap smear at age 21, but her friend told her that Pap smears are only done every 5 years. Which statement by the nurse practitioner would be appropriate education to provide the patient regarding routine Pap smears?

At the age of 30, a patient can receive routine Pap smears every 5 years if a combination of cytology and high-risk HPV testing (cotesting) is performed The American College of Obstetrics and Gynecology cervical cancer screening guidelines recommend that patients receive routine Pap smears every 3 years starting at age 21 despite current sexual activity

A 64-year-old woman reports that for the past year, she has experienced worsening vaginal dryness, especially during sexual activity. In addition, she is experiencing vulvovaginal pain, burning, and yellow vaginal discharge. A speculum exam reveals smooth and shiny vaginal walls, yellow discharge, and a vaginal pH of 5.5. Which of the following is the most likely diagnosis for this patient?

Atrophic vaginitis Also called genitourinary syndrome of menopause, is caused by a lack of estrogen and most commonly occurs in postmenopausal patients. With a lack of estrogen, there is a loss of superficial epithelial cells that causes thinning of vaginal tissue, loss of vaginal rugae, decreased vaginal wall elasticity, and a shortening of the vagina. There may also be a loss of subcutaneous fat in the labia majora, narrowing of the introitus, and fusion of the labia minora. These changes can cause symptoms, including vaginal dryness, abnormal discharge, burning, itching, dyspareunia, and postcoital bleeding. The physical signs noted during a speculum exam include a decrease in vaginal rugae, smooth and shiny vaginal epithelium, friability of vulvovaginal tissue, and pH of ≥ 5.Atrophic vaginitis can be treated with vaginal estrogen, vaginal lubricants, moisturizers, and systemic therapies if vasomotor symptoms of menopause are also present.

A young female patient of reproductive age presents with severe abdominal pain and abnormal vaginal bleeding. Which of the following signs and symptoms is not associated with ruptured ectopic pregnancy?

Both clonus (involuntary muscle contractions of the hands, ankle, or jaw, for example) and proteinuria are typically seen in patients with severe preeclampsia, not with an ectopic pregnancy

A 23-year-old woman presents to the clinic today with concern over a recent mobile lump she felt in her right breast. She states one is starting to form in her left breast as well. She has no significant past medical history but does report a lot of stress at her new job. Which of the following is the least likely diagnosis given the patient's age and presenting history?

Breast cancer the least likely diagnosis, as it is most common in postmenopausal patients and typically presents as a unilateral, fixed lump. Malignant masses are also primarily nontender, firm, or hard with poorly delineated margins. If a mass with the listed characteristics is palpated, the patient should be referred for diagnostic mammography.

Contraindications to ED meds:

Cardiac conditions are almost always contraindicated in the use of PDE5 inhibitors due to the risk of interaction with any dosage formulation of nitrate. A patient who had a myocardial infarction in the last year will most likely have been prescribed nitrates for chest pain. It is contraindicated in male patients with multiple myeloma because of the increased risk of priapism. PDE5 inhibitors can lead to further visual side effects and damage to the retina in pigmentary retinopathy

Sexually transmitted pathogens and are the most common causes of epididymitis in patients who are younger than 35 years

Chlamydia trachomatis and Neisseria gonorrhoeae

A 28-year-old woman presents to the clinic today with a swollen, erythematous right breast. She states that this began in the last few days, and her pain increases every time she tries to breastfeed. You suspect a possible diagnosis of acute mastitis and decide to treat her with antibiotics. Her medical history includes generalized anxiety disorder, lupus, and exercise-induced asthma. She also reports having shortness of breath and facial swelling after taking amoxicillin-clavulanate (Augmentin) as a child. Which of the following antibiotics would be appropriate to prescribe for this condition?

Clindamycin (Cleocin) Clindamycin (Cleocin) as well as erythromycin (Eryderm) are appropriate alternative options to treat this patient's acute mastitis. Clindamycin and erythromycin do not have a risk for cross-reactivity with penicillin-based or cephalosporin antibiotics.

A patient presents to the clinic reporting a milky white vaginal discharge that has persisted for the last few days. The patient reports having a heterosexual monogamous relationship, rarely using condoms, and consistently using oral contraceptives. The nurse practitioner performs a wet mount. The results are negative for white blood cells but positive for clue cells. Which of the following is the most appropriate plan of care for this patient?

Clue cells are a hallmark sign of bacterial vaginosis. The classic presentation of milky white vaginal discharge with clue cells raises strong suspicion for bacterial vaginosis. A diagnosis of bacterial vaginosis is made if there is an adherent and homogeneous discharge, a positive whiff test (indicating the presence of bacteria), clue cells (epithelial cells covered by adherent gram-negative rods), or a vaginal pH > 4.5. This bacterial infection is not contagious and can be treated with oral metronidazole (Flagyl), vaginal metronidazole (Metrogel Vaginal), or clindamycin (Cleocin-T) cream.It is important to instruct patients to avoid douches, as use is known to raise vaginal pH > 4.5 and create a favorable environment for this type of infection. A normal vaginal pH is ≤ 4.5.

Exercise to reduce risk of Osteoporosis?

Dancing, hiking, and jumping rope are all examples of weight-bearing exercises and should be included in education about reducing one's risk for osteoporosis.

A woman who is breastfeeding presents with an erythematous, tender left breast. She states she can feel a lump, but it is painful to touch. It started a couple of days ago as just a sore area, but it now has progressed and is accompanied by a fever and chills. She is 2 weeks postpartum. Her temperature is 101°F, and her heart rate is 100 bpm. The area on the upper outer quadrant of the left breast is erythematous, warm, and painful to palpation. Which of the following is the most appropriate next step in management?

Dicloxacillin 500 mg four times a day for 10 to 14 days is a first-line treatment for mastitis. Lactational mastitis typically occurs in the first 12 weeks of breastfeeding and causes a breast to become painful, swollen, red, and warm. The clinical presentation can range in severity from painful inflammation to systemic symptoms such as fever and flu-like symptoms. Mastitis is a clinical diagnosis, and breast milk cultures are not routinely done It is also important to advise the patient to continue frequent breastfeedings to ensure complete emptying of the breasts during the treatment. When milk remains in the breast, milk stasis can increase the risk of recurrence. A delayed or skipped feeding causing milk stasis can be enough to trigger mastitis in some patients.

Which of the following pathogens is the most likely cause of acute epididymitis in a 57-year-old patient?

Escherichia coli Acute epididymitis is the most common cause of scrotal pain in outpatient settings. The most likely cause of acute epididymitis in a 57-year-old patient is Escherichia coli. This pathogen is the most common cause of acute epididymitis in patients who are 35 years and older, often due to a urinary obstruction from benign prostatic hypertrophy. The epididymis is located on the posterior aspect of the testis. Signs and symptoms of acute epididymitis include localized testicular pain and swelling and tenderness to palpation of the affected epididymis. A positive Prehn sign is indicated by an improved pain level with manual elevation of the patient's scrotum. Patients with suspected acute epididymitis should complete a urinalysis, urine culture, and urine nucleic acid amplification test for Chlamydia trachomatis and Neisseria gonorrhoeae. Outpatient treatment includes oral antibiotics, NSAIDs for pain relief, and ice application to the affected area.

A pregnant patient presents to the clinic today for her annual wellness exam. As the nurse practitioner, you are precepting a student who is asking about probable versus positive signs of pregnancy. Which of the following is an example of a positive sign of pregnancy?

Fetal heart tones detected by Doppler Positive signs of pregnancy are objective findings that are detected and documented by the nurse practitioner. Fetal heart tones detected by Doppler is an example of a positive sign of pregnancy. Other positive signs include fetal movement felt by the nurse practitioner and visualization of the fetus with sonography.

A 43-year-old woman recently had a baby in the last 6 weeks. She has been attempting to breastfeed but is having issues with increased breast tenderness and reduced milk supply. Which of the following signs or symptoms distinguish acute mastitis from inflammatory breast cancer?

Fever In both acute mastitis and inflammatory breast cancer (IBC), it is common for the affected breast to become larger and for breast erythema to be present. Fever is only present in those with acute mastitis and is not associated with a diagnosis of IBC, which helps to differentiate between the two. If an episode of acute mastitis does not resolve with appropriate treatment, a diagnosis of IBC should be considered.

Which of the following supplements is most important for a newly pregnant patient to be taking every day?

Folic acid is an essential supplement during preconception and pregnancy to prevent neural tube defects, which are the result of folic acid deficiency. A complete prenatal multivitamin is also important during pregnancy to make sure the mother is able to supply all necessary nutrients to the growing fetus. Ideally, folic acid supplements and prenatal vitamins would be started 2-3 months before conception. The recommended dose of folic acid is 400 mcg once daily.

A 25-year-old woman presents to the clinic for preconception counseling. The patient asks about folic acid and why it is so important for patients of childbearing age to take it. Which of the following teaching statements would be the most appropriate?

Folic acid supplementation during pregnancy reduces the incidence of neural tube defects in the fetus

A 35-year-old woman presents for preconception counseling. She reports having one child 3 years ago, who was born with spina bifida. She is asking how to prevent this in future pregnancies. Which of the following statements is the most appropriate education for the patient?

High-dose folic acid supplementation of 4,000 mcg daily This is recommended for patients with prior children with neural tube defects. Neural tube defects are one of the most common congenital abnormalities in the United States. Women who have had a prior child with neural tube defects are 10 times as likely to have another child with neural tube defects. Folic acid supplementation of 400 mcg to 800 mcg daily is recommended for all patients of childbearing age. High-dose prophylaxis of folic acid 1,000 mcg to 4,000 mcg daily is recommended for patients at high risk. This treatment should be initiated 1 to 3 months prior to attempted conception. This should be done in the short term only to prevent folic acid toxicity.

A 26-year-old woman was previously seen for a routine Pap smear and received a result of atypical squamous cells of undetermined significance. How should the nurse practitioner explain this finding to the patient?

If a Pap shows positive atypical squamous cells of undetermined significance (AS-CUS), HPV testing should be ordered as the next step in management.

The nurse practitioner is seeing a patient who is 37 weeks pregnant for a routine prenatal visit. It is noted in her chart that she tested positive for group B Streptococcus(GBS) at her last visit. The nurse practitioner also notes she has a penicillin allergy. The patient asks what medication she will need during labor, to protect the baby. Which is the most appropriate response?

If a patient is allergic to penicillin, IV clindamycin may be used Patients are tested for GBS between 36 and 37 weeks gestation. Although GBS is dangerous to the fetus, it is possible to deliver vaginally when the appropriate antibiotic prophylaxis is administered intrapartum. The preferred treatment is IV penicillin G or ampicillin Another alternative is a first-generation cephalosporin, which may be used in those with a history of mild penicillin reaction. Consideration may also be given to perform penicillin allergy testing, especially in those who have an allergy of unknown severity.

Emergency contraception should be considered when?

If a patient misses two or more consecutive active pills in the first week of a cycle and if unprotected intercourse occurs during this timeframe, as ovulation is more likely to occur.

A pregnant patient at 26 weeks gestation presents to the clinic. She was recently diagnosed with gestational diabetes. Which of the following medications is considered the safest first-line treatment for this patient?

Insulin the first choice for management of gestational diabetes, as it does not cross the placenta, reducing the effects of the medication on the fetus. Insulin therapy is considered a safe and effective way to manage blood glucose in pregnant patients. Optimization of blood glucose leads to decreased weight gain, decreased incidence of macrosomia, reduced risk for neonatal hypoglycemia, and reduced neonatal birth weight.Gestational diabetes requires close monitoring and management to prevent adverse maternal and fetal outcomes. The goal of medication for a patient with gestational diabetes is to keep glucose levels under the targeted upper limit of the range and to prevent episodes of hypoglycemia. For patients who cannot keep glucose levels within range with dietary and lifestyle changes alone, medication should be considered.

A 33-year-old patient who is newly pregnant presents to the clinic. She asks the nurse practitioner questions regarding which vaccines she can receive during her pregnancy. Which vaccine would not be safe to receive during her pregnancy?

Intranasal influenza It is recommended that pregnant patients receive all necessary scheduled vaccines prior to pregnancy. During pregnancy, it is safe for mothers to receive most vaccines except those that are live vaccines. Intranasal influenza is thus not safe for this patient to receive. Other live vaccines include smallpox, yellow fever, varicella, and measles-mumps-rubella vaccines. Vaccinations protect the fetus and mother from complications and mortality from preventable diseases. Immunizations can provide passive immunity to the fetus. The Tdap and injectable influenza vaccination are routinely recommended for all pregnant patients. There is no evidence of harm to the fetus with inactivated vaccinations.

PCOS:

Is an endocrine disorder with an unknown etiology. Approximately 5-10% of reproductive-age patients are diagnosed with this disorder. The Rotterdam criteria identify hyperandrogenism, ovulatory dysfunction, and polycystic ovaries as the key diagnostic features of the disorder. At least two of these features must be present to meet diagnostic criteria. Common symptoms of PCOS include irregular menses and presentations associated with hyperandrogenism, which include acne, hair loss, and hirsutism. Mood changes, such as depression and anxiety, may also be present.

Breast Cancer:

Is the leading cancer diagnosis worldwide, and early detection is key to survival. Nurse practitioners use risk assessment tools to place patients into categories (average, moderate, and high risk). Patients with a hereditary breast cancer risk without genetic testing fall into a moderate risk category and should be encouraged to consider genetic testing when possible. For those who have a moderate and high risk, professional breast exams should be completed every 6 to 12 months, with mammograms and MRIs completed yearly. Surveillance should start 10 years before the age that the youngest family member was diagnosed with breast cancer, but not before 30 years old for mammograms and 25 years old for MRIs.

A 40-year-old woman presents to the clinic and wants to discuss her family history of breast cancer. She reports that her mother died at the age of 51 from breast cancer and wants to know what her treatment options are should she develop breast cancer herself. What is the best way for the nurse practitioner to respond to these concerns?

It is important to address questions and concerns, so stating a lumpectomy with radiation therapy is an option if the breast cancer is caught early Is an appropriate response to directly address the patient's question. If caught early, the breast cancer has likely not metastasized, and removing the tumor with a lumpectomy followed by targeted radiation therapy to the area to eliminate any remaining tumor cells can significantly decrease the risk of recurrence.

A newly pregnant woman presents to the clinic today with concerns about what foods she can and cannot safely eat during pregnancy. Which of the following statements is incorrectregarding a possible Listeriainfection?

It would be incorrect to educate the patient that Listeriais uncommon in pregnant patients and only poses a mild concern Per the Centers for Disease Control and Prevention (CDC), pregnant patients are 10 times more likely than the general population to contract a Listeria infection. A Listeria infection is an illness usually caused by eating foods contaminated by the Listeria monocytogenes bacteria, which primarily affects pregnant patients, newborns, older adults, and patients who are immunocompromised

Listeriosis:

Listeriosis is a serious infection and poses a high risk in pregnant patients as it can lead to spontaneous abortion, premature birth, infection to the newborn, and potential fetal demise or stillbirth. Often, symptoms do not begin for weeks after exposure but can appear as early as several days after. It is recommended that pregnant patients avoid unpasteurized products, including milk, juices, and ciders

Which of the following factors is associated with an increased risk for premature onset of labor and delivery?

Mothers with a short cervix (≤ 25 mm) are at an increased risk of delivering a baby prematurely due to the cervix dilating early, often between 12 and 20 weeks gestation. The risk of premature birth increases with a shorter cervical length, and mothers are often asymptomatic.

An 18-year-old man presents to the clinic for evaluation of bilateral swelling and pain in the scrotum. He lives in a college dormitory and reports he is not sexually active. He has not received any childhood vaccines. The exam is significant for a fever of 41ºC, severe testicular pain, and swelling and erythema of the scrotum. Which of the following diagnoses should be prioritized on the differential diagnosis?

Mumps orchitis Is associated with fever, testicular and scrotal pain, as well as erythema and edema. Among male patients with mumps, 20-30% develop orchitis, polyarthritis, or thyroiditis in addition to parotid gland swelling. Risk factors for developing mumps are living in a crowded environment such as a dormitory, traveling globally, and being unvaccinated against mumps. Treatment is supportive and includes NSAIDs and ibuprofen for pain and fever. Ice packs and scrotal elevation may help relieve symptoms of orchitis.

A 32-year-old woman presents to the clinic to discuss contraception after the birth of her second child. Her medical history includes anxiety, depression, GERD, and systemic lupus erythematosus. Which of the following contraceptive options is the least appropriate for this patient?

Norelgestromin-ethinylestradiol transdermal patch Estrogen-containing contraceptives, such as the norelgestromin-ethinylestradiol transdermal patch, are not recommended for patients with systemic lupus erythematosus (SLE) due to associated increased risk for cardiovascular disease and thromboembolism. Estrogen is contraindicated in patients with antiphospholipid syndrome, which is an autoimmune disorder that causes a significantly increased risk of thromboembolism and is often associated with SLE. Immunosuppressive, anticoagulant, and anticonvulsant medications commonly used in SLE also interact with estrogen.Contraception is an essential aspect of care for patients with SLE, as the peak incidence occurs in the female population of reproductive age. Several medications for this condition are teratogenic, such as methotrexate, and pregnancy should be avoided while taking these. Long-acting reversible contraceptives, such as intrauterine devices, are the preferred choice of contraception for patients with SLE, as they do not contain estrogen and have high rates of efficacy. Emergency contraception is an option for patients with SLE. SLE does not affect fertility, but patients should be advised to pursue pregnancy when the disease is stable with low activity due to risk of pregnancy complications.

A 24-year-old woman presents for her routine Pap smear. Her last Pap smear was performed 3 years ago and resulted with normal findings. Upon cervical exam, you notice an erythematous cervix with some purulent discharge around the cervical os. She states she has been having unprotected sex with more than one partner and was last tested for sexually transmitted infections a couple of years ago. Based on this information and these clinical findings, what would be the priority test to order today?

Nucleic acid amplification testing Nucleic acid amplification testing on vaginal swabs (preferred for female patients) or urine (preferred for male patients) is the recommended screening test for chlamydia, gonorrhea, and trichomoniasis. These sexually transmitted infections (STIs) commonly present with no symptoms, which is why cervical exams are so valuable. Female patients may experience vaginal discharge, intermenstrual bleeding, and postcoital bleeding. Male patients sometimes experience urethritis but can also transmit infection with no symptoms. On cervical exam, the practitioner may see classic findings of cervicitis, including mucopurulent endocervical discharge, friability, and ectropion.

Positive signs of pregnancy:

Objective findings from the nurse practitioner such as auscultation of fetal heart tones, palpation of fetal movement, or ultrasound confirmation.

Ectopic pregnancy:

One that occurs anywhere outside of the uterus, whether it be the fallopian tube, ovary, cervix, or abdominal cavity. The risk of rupture is greatest when the fertilized egg implants in the fallopian tube and continues to grow, exceeding the size of the area. This can lead to heavy bleeding inside the abdomen and peritonitis and can become life threatening. Typical treatment for an ectopic pregnancy without unstable bleeding usually entails administering methotrexate, which stops the embryo's cells from growing and dividing, eventually ending the pregnancy. In patients who are experiencing heavy bleeding, emergency surgery may be performed to prevent long-term complications. The Cullen sign, a bluish discoloration around the umbilicus, may present due to intra-abdominal bleeding associated with an etopic pregnancy. A heart rate of 139 bpm suggests tachycardia and is likely to be seen in a ruptured ectopic pregnancy due to fluid volume loss. In addition, a positive Blumberg sign, pain that occurs after palpation of the abdomen is released, is possible in a ruptured ectopic pregnancy, as it can cause peritonitis.

A 26-year-old woman has a Pap smear result of atypical squamous cells of undetermined significance. What is the best next step in management?

Order for HPV testing Cervical cancer screening should be performed for women between the ages of 21 and 65 with cytology every 3 years. For women aged 30 to 65, screening is performed with cytology and human papillomavirus (HPV) testing every 5 years. The US Preventive Services Task Force (USPSTF) recommends against routinely co testing with cytology and HPV for women younger than 30 years old. If a Pap shows positive atypical squamous cells of undetermined significance (ASC-US), HPV testing should be ordered. After the age of 65, screening can be discontinued if there is adequate prior screening. A colposcopy should be performed if there are AS-CUS or squamous intraepithelial lesions on cytology. A Pap smear should be repeated in 1 year if a Pap smear is positive for AS-CUS and HPV is negative. A Pap smear can be repeated in 3 years with cervical cytology alone.

The American Cancer Society's cervical cancer screening guidelines are relied upon by nurse practitioners. Which of the following statements is incorrect regarding human papillomavirus (HPV) screening and Pap smears?

Pap smears have a higher sensitivity than HPV tests According to the American Cancer Society, HPV testing is more sensitive and specific compared to the Pap smear. The HPV test is a screening measure that detects infection by high-risk types of HPV. It can be conducted alone or with the Pap test, which is also known as a cotest. There are various recommendations for screening the average-risk patient, depending on age and medical history. These guidelines have recently been updated to avoid screening patients under the age of 21, regardless of sexual activity. The guidelines have also changed from annual screening to every 3-5 years depending on age and medical history.

A 34-year-old woman is at 33 weeks gestation and has been taking enoxaparin (Lovenox) injections, as prescribed, throughout her pregnancy. She desires an epidural for pain relief during labor. Which of the following counseling statements is indicated, to promote patient safety?

Patients should be instructed to stop administering injections at least 18-24 hours prior to receiving spinal or epidural anesthesia Enoxaparin is the anticoagulant of choice in pregnant patients who are considered candidates for prophylactic or therapeutic heparin therapy. Patients should be instructed to stop administering injections at least 18-24 hours prior to receiving spinal or epidural anesthesia. This is to reduce the risk of spinal hematoma.

A lactating patient presents to the clinic for a visit as her symptoms of mastitis have not improved after completion of susceptible antibiotics per culture sensitivity. She states she has not had any further fevers, but her breast is still extremely painful, erythematous, and edematous. Which of the following is the best course of action for this patient?

Patients treated for mastitis who do not experience total resolution of their symptoms after recommended therapeutic treatment should be referred for a breast ultrasound and possible mammogram Breast cancer can be misdiagnosed as mastitis initially, thus this patient's mastitis needs to be investigated further.

A patient who is 38 weeks pregnant presents for her routine prenatal visit. She states she has had some painless bright red bleeding in the last 24 hours accompanied by mild contractions. This has made her extremely nervous about the health of her fetus. Upon exam, her uterus is soft and nontender. Which of the following is the most likely diagnosis?

Placenta previa Is the result of the placenta being in an unusual location, usually over or near the internal cervical opening (os). It is often characterized by bright red, painless bleeding with a soft, nontender uterus. This can lead to excessive bleeding in the antepartum, intrapartum, or postpartum period, thus placing the patient at high risk for preterm birth and maternal and fetal morbidity. Close monitoring throughout the duration of the pregnancy is required. Additionally, vaginal exams and sexual intercourse should be avoided.

A patient who is 36 weeks pregnant presents with vaginal bleeding, a hard stomach, and painful contractions. Which of the following is the priority action?

Placental abruption is an emergent complication of pregnancy where the placenta separates from the uterus before birth due to ruptured maternal blood vessels When this occurs, it puts the placenta's blood supply, and thus the pregnancy, at high risk. This patient needs to be evaluated as soon as possible in the emergency department. Clinical findings often include abrupt onset vaginal bleeding, abdominal pain, a hard stomach, uterine contractions, uterine tenderness, and a non reassuring fetal heart rate.

Leopold maneuvers are an example of which sign of pregnancy?

Positive signs of pregnancy include objective findings, such as fetal heart tones, palpation of the fetus, and ultrasound detection of a fetus. The Leopold maneuvers are used to palpate the gravid uterus systematically. This is abdominal palpation

Placenta previa:

The placenta covering the cervix. Risk factors can include increased maternal age, smoking, multiple births, and previous cesarean sections. The characteristic sign of placenta previa is painless vaginal bleeding, and the treatment includes pelvic rest, which includes avoiding sexual activity that may cause trauma resulting in vaginal bleeding. After 37 weeks gestation, a cesarean section may be scheduled for delivery.

A 31-year-old pregnant person presents to the office for routine prenatal care. They are 25 weeks pregnant, and their gestational diabetes screening came back positive. Knowing the risks of gestational diabetes, the nurse practitioner educates the patient on the importance of glycemic control during pregnancy. Which of the following is a complication of hyperglycemia during pregnancy?

Preeclampsia a complication of untreated gestational diabetes and hyperglycemia. Gestational diabetes can affect both the pregnant person and the infant in multiple ways. Infants born to pregnant people with uncontrolled gestational diabetes can develop macrosomia and be large for gestational age at birth. As a result, shoulder dystocia and cesarean sections are also a risk for patients with untreated gestational diabetes. A long-term risk for pregnant people with gestational diabetes is developing type 2 diabetes later in life.Lifestyle modification is the mainstay of treatment for gestational diabetes. Many pregnant people manage this condition with diet and exercise alone. Insulin is the first-line treatment if glycemic control does not occur with lifestyle modification. Metformin and glyburide (Diabeta) are second-line treatments and are not FDA approved for gestational diabetes.

A woman at 26 weeks gestation was recently diagnosed with placenta previa after she experienced vaginal bleeding after having intercourse. What is the best education to give her, to reinforce instructions given by the obstetric team, in regard to her new diagnosis?

Recommendation for this patient is pelvic rest to reduce the risk of bleeding Pelvic rest is recommended for patients diagnosed with placenta previa who are over 20 weeks pregnant

A 20-year-old woman presents to your office for evaluation. She states she would like to be tested for all possible sexually transmitted infections, as she is sexually active and is unsure of her last partner's status. Which of the following would be an inappropriate test to order?

Reflex HPV DNA testing Due to her age, this patient does not need HPV testing. This is because younger female patients typically clear the infection so quickly that it usually does not progress to any further abnormalities. Current guidelines recommend beginning cervical cancer screening with cytology alone at age 21, and routine HPV testing should begin at age 25 and be performed every 5 years for patients at high risk.

A 20-year-old woman presents for contraceptive counseling. After talking to her friends, she believes the contraceptive patch will be her best choice because taking a daily pill is difficult for her to remember. She requests a prescription for the levonorgestrel-ethinyl estradiol transdermal system (Twirla patch). Which of the following medical conditions would be a contraindication to this method of contraception?

SLE and positive antiphospholipid antibodies The levonorgestrel-ethinyl estradiol transdermal system (Twirla patch) is a combined hormonal contraceptive containing estrogen and progestin. Patients with systemic lupus erythematosus (SLE) have an increased risk of arterial and venous thrombosis and myocardial infarction, and the presence of antiphospholipids antibodies further increases the risk. Combined hormonal contraception is contraindicated

A patient is approaching her second trimester and has concerns regarding future testing. She would like to know when she will be tested for gestational diabetes. During which time frame can the patient anticipate being tested for gestational diabetes?

Screening for gestational diabetes takes place between 24 and 28 weeks

A 27-year-old patient is at the office requesting recommendations for an obstetrician because she would like to get pregnant within the next few months. While reviewing the patient's vaccination records, the nurse practitioner notices that she has had only one dose of the MMR vaccine at 19 years old. Knowing that the patient is trying to become pregnant, what must the nurse practitioner tell her regarding the MMR vaccine?

She must avoid getting pregnant for at least 4 weeks following vaccination The MMR vaccine, a live attenuated virus vaccine, should be given to patients who do not have evidence of immunity to measles, mumps, and rubella, including documentation of completion of MMR vaccination and laboratory evidence of immunity. The MMR vaccine should only be given to nonpregnant patients. If a person is planning to become pregnant and is not vaccinated, they must avoid getting pregnant for at least 4 weeks following vaccination

A 53-year-old woman presents to the clinic with an interest in discussing hormone replacement therapy for menopausal symptoms. Which of the following elements of the patient's health history makes her a candidate for hormone replacement therapy?

Smoking Smoking is not advised while taking hormone replacement therapy, but it is not a contraindication. The decision to initiate hormone replacement therapy is highly individualized, and the decision should be made in collaboration with the patient, as there is no perfect risk to benefit ratio for initiating therapy. Hormone replacement therapy is often used as a broad term to describe any hormone supplementation. The Food and Drug Administration uses the term hormone therapy to describe only combination estrogen-progestogen. Hormone therapy is the most effective treatment for vasomotor symptoms (e.g., hot flashes, night sweats), genitourinary syndrome of menopause (e.g., loss of vaginal elasticity), and prevention of fracture and bone loss. Estrogen therapy alone is appropriate for patients who have had a hysterectomy, but progesterone is required if the patient still has a uterus. Unopposed estrogen administration in patients with a uterus increases the risk of endometrial cancer. Low-dose, topical estrogen therapy may be indicated for patients with vaginal dryness, recurrent urinary tract infections, or dyspareunia.

An adult woman nearing menopause asks the nurse practitioner about exercises she can do to help prevent "brittle bones" in the future. Which of the following exercises should the patient not be advised to consider?

Swimming is not considered a weight-bearing exercise, which is recommended for the prevention of osteoporosis. There are several lifestyle interventions women can adopt to help reduce their risk of osteoporosis as they age. Such measures include adequate nutrition, exercise, smoking cessation, and avoidance of heavy alcohol use. Women are recommended to engage in at least 30 minutes of weight-bearing exercise most days of the week. Exercises that increase muscle strength and promote balance are also important for reducing fall risk.

A 23-year-old woman presents to the clinic for her annual physical examination with concerns of irregular menstrual cycles. She notes that within the last year, she has only had four periods and has gone more than three consecutive months without a period. If polycystic ovary syndrome is suspected, which symptom is least likely to be observed in this patient?

Symptoms such as vaginal itching or vaginal irritation are not commonly associated with polycystic ovary syndrome (PCOS)

A 46-year-old woman presents to the office for her annual gynecological well-visit. She tells the nurse practitioner a friend of hers was recently diagnosed with breast cancer. She does not have any family history of breast cancer, but her father had skin and colon cancers. She is concerned and would like recommendations for cancer screening tests. Which of the following is the most appropriate recommendation for this patient?

The American College of Obstetricians and Gynecologists recommend annual mammograms starting at age 40 For women at average risk of breast cancer, screening mammography is recommended every 1-2 years. Patients should start having mammography no later than age 50 years. Screening should continue until at least age 75 years.

A 23-year-old man presents to the office with concerns of yellow/green penile discharge and pain with urination. The patient reports a poor hydration status, multiple new sexual partners over the past year, and occasional use of condoms. The vital signs are as follows: weight 180 lbs, blood pressure 120/60 mm Hg, pulse 68 bpm, and temperature 98.4°F orally. A nucleic acid amplification test is positive for gonorrhea and negative for chlamydia. What is the best treatment plan for this patient?

The CDC recently updated the treatment guidelines for gonorrhea and chlamydia. For individuals weighing < 150 kg, gonorrhea infections are to be treated with a single intramuscular dose of ceftriaxone (Rocephin) 500 mg For individuals weighing ≥ 150 kg, 1 g ceftriaxone intramuscular in a single dose should be administered. A patient who is appropriately treated does not require a test of cure. Specific to chlamydia, for individuals weighing <150 kg, chlamydia (confirmed or suspected) should be treated with doxycycline 100 mg orally twice daily for 7 days.

A 33-year-old woman presents to the office reporting 1 week of sore, cracking nipples due to breastfeeding her newborn infant. She is 2 weeks postpartum. She reports no fevers, chills, warmth, erythema, or painful nodules in her breast that would suggest mastitis. Which of the following is the most appropriate next step in management?

The best next step in management is to advise to continue breastfeeding and order a lactation consult to assess the infant's latch Sore and painful nipples are a common complication in the first couple weeks of breastfeeding. The most common cause is a poor latch which is often due to improper positioning, tongue tie, or infant oral thrush infection. The nurse practitioner should assess the infant's latch and provide immediate coaching on breastfeeding technique as well as refer the patient to a lactation consultant for ongoing support. Often, lactation consultants will encourage participation in a breastfeeding support group that includes weekly (or bi-weekly) in person breast feeding clinics. If the infant has a thrush infection, this should be treated.

A 28-year-old G1P0 pregnant patient presents for a routine prenatal visit at 14 weeks of gestation. Their prenatal lab test results include blood type B negative and other results are normal. The patient is up to date on immunizations. Which of the following is the best next step in their prenatal care?

The best next step in prenatal care for this patient is to schedule a RhoGAM shot at 28 weeks This reduces the risk for isoimmunization by 99%. Recall that there are several antigens within the Rh group (C, c, D, d, E, e, G). Rh incompatibility occurs when the pregnant person is Rh negative and exposed (most commonly) to fetal D antigen (Rh positive) either in the antepartum period or by fetomaternal passage of fetal red blood cells. Once maternal red blood cells are exposed to the D antigen, the production of anti-D antibodies begins. These maternal IgG antibodies can cross the placenta, enter the fetal circulation, and destroy fetal red blood cells. The result is Rhesus (Rh) incompatibility, or hemolytic disease of the newborn. In severe cases of hemolysis, hydrops fetalis or death can occur.Rh testing typically occurs at the first prenatal appointment, in some circumstances it will be repeated at 28 weeks for confirmation. During pregnancy, at 28 weeks of gestation, patients who are D negative and have a negative anti-D antibody screen are administered RhoGAM. RhoGAM is an anti-D immune globulin administered intramuscularly at 28 weeks of gestation to Rh negative mothers. RhoGAM prevents isoimmunization by suppressing the pregnant patient's immune response and subsequent antibody formation if exposed to Rh-positive red blood cells. If the baby is Rh positive at birth, a second dose of RhoGAM will be administered within 72 hours of delivery. Long-term, Rh negative pregnant patients will receive RhoGAM during every pregnancy unless already sensitized.

A 28-year-old woman who is pregnant at 36 weeks gestation presents to the clinic for her routine prenatal appointment. Her urinalysis reveals no leukocytes, nitrites, or blood, but it is positive for protein. She reports increased urination with good hydration, no abdominal pain, and no unusual bleeding. She has gained 5 lbs since her visit 1 week ago and reports increased swelling in her hands. Her blood pressure at the present visit is 158/92 mm Hg and 162/100 mm Hg, consecutively. Which of the following diagnoses should be prioritized on the differential diagnosis list?

The classic symptoms of preeclampsia Elevated blood pressure, unexpected weight gain, edema, and proteinuria. The largest risk of preeclampsia is that it develops further into eclampsia. The only cure is to deliver the fetus and placenta, but with only mild symptoms, it is not urgent to do so. Hypertension is the most common medical condition during pregnancy. Preeclampsia and eclampsia are the most dangerous forms of hypertension during pregnancy. Other causes include gestational hypertension and chronic hypertension. Characteristic symptoms of preeclampsia are new-onset hypertension and end-organ dysfunction with or without proteinuria in the last half of pregnancy or the postpartum period. Risk factors associated with this condition include preexisting hypertension, molar pregnancy, multiple gestations, chronic kidney disease, previous preeclampsia, obesity, and age older than 35 years. Nifedipine is the recommended antihypertensive, but labetalol and methyldopa may be used as well. Target blood pressure goals range between 120 and 160 mm Hg systolic and 80 and 105 mm Hg diastolic to avoid compromised uteroplacental flow with pharmacologically induced hypotension. Severe preeclampsia presents as severe headaches that are not relieved with rest and acetaminophen, right upper quadrant pain, shortness of breath, and visual changes. Eclampsia, also known as status epilepticus, requires emergent delivery, regardless of the age of the fetus.

A woman who is 28 weeks pregnant was diagnosed with gestational diabetes mellitus at today's visit after completing her oral glucose tolerance test. She reports that she has a fear of needles and would hate to have to give herself insulin injections multiple times a day. Which of the following is true regarding the treatment of gestational diabetes?

The first-line treatment for gestational diabetes mellitus is lifestyle modifications The patient should follow a meal plan involving three meals and two to three snacks per day that are low in carbohydrates. Low-intensity exercise should be performed for 30 minutes a minimum of 5 days per week. Glucose levels must be checked frequently to evaluate the effectiveness of lifestyle modifications. If glucose levels are not controlled with these interventions, insulin is the next recommendation per the current standard of care, unless circumstances preclude its use. In those cases, metformin is a reasonable choice. The American College of Obstetrics and Gynecology recommends insulin as the preferred therapy if glycemic control is not obtained with nonpharmacologic treatment.

A 29-year-old woman who is 16 weeks pregnant presents with vaginal bleeding. Upon cervical exam, the nurse practitioner notes that the cervix is dilated and thinning. The patient states she is very worried she will lose the fetus. Which of the following is the least appropriateresponse?

The least appropriate response to the patient is that while this is a threatened abortion, it is possible with bed rest that the pregnancy can be saved An inevitable abortion occurs when the cervix dilates and the fetus is expelled. There is no intervention to halt this process, but it does not impact a patients's ability to carry a future pregnancy to term. This patient should be referred to obstetrics for follow-up care. A threatened abortion happens when there is bleeding but no cervical dilation, but the fetus will not necessarily be expelled. In cases of threatened abortion, it may be possible to carry the pregnancy to term.

A 25-year-old patient presents to the clinic for contraceptive counseling. She asks the nurse practitioner if combined oral contraceptives increase the risk of cancer. Which of the following is the most appropriate response by the nurse practitioner?

The most appropriate response by the nurse practitioner is that patients who take combined oral contraceptives (COCs) may have a slightly higher risk of cervical and breast cancer The link between these medications and cancer risk has been researched with large observational studies. Although an increased risk of cervical and breast cancer is associated with COCs, research demonstrates this risk decreases over time after a patient stops taking the medication.A COC is a medication used to prevent pregnancy that contains estrogen and progesterone. These medications suppress gonadotropin-releasing hormone, follicle-stimulating hormone, and luteinizing hormone to prevent ovulation. COCs are also associated with an increased risk of venous thromboembolism and hypertension. Rare risks of severe cardiovascular disease, including myocardial infarction and stroke, are associated with this contraceptive medication class.

A 28-year-old woman is requesting long-acting reversible contraception and would like information regarding the side effects of nonhormonal choices. Which of the following are common side effects associated with the copper intrauterine device?

The most common side effects associated with copper intrauterine devices (IUDs) are heavy menstrual bleeding and menstrual pain Complications of all IUDs are uncommon and include uterine perforation, device expulsion, and ectopic pregnancy in the rare event of IUD failure. Both hormonal and nonhormonal IUDs can be used in female adults and adolescents, regardless of parity history. There are few contraindications for using an IUD, and they should be routinely offered to most women. IUDs and dermal implants are the two long-acting reversible contraceptive methods available, and they are both effective with a < 1% failure rate. Dermal implants and several types of IUDs have a hormonal component. The only nonhormonal IUD available in the United States is the copper IUD. It is T-shaped, and the arms and stem are wrapped with copper wire. The copper IUD's primary mechanism of action is preventing fertilization by inhibiting sperm migration and viability. It does not interrupt a pregnancy. It remains in place and is effective for 10 continuous years.

A 30-year-old patient presents to the clinic for her annual physical examination. She reports she read online that birth control pills reduce the risk of cancer. The nurse practitioner should advise the patient there is a decreased risk of which of the following cancers in patients who take combined oral contraceptives?

The nurse practitioner should advise the patient that there is a decreased risk of endometrial and ovarian cancer Patients who take combined oral contraceptive (COC) medications. Endometrial cancer risk is reduced by at least 30% with COC use. Patients who have taken COCs have a 30-50% reduced risk of ovarian cancer, and the duration of cancer protection increases the longer the duration of COC use. Research demonstrates risk reduction for endometrial and ovarian cancer persists for years after COCs are discontinued. COCs contain estrogen and progesterone components, which suppress follicle-stimulating hormone, gonadotropin-releasing hormone, and luteinizing hormone to prevent ovulation. Common early side effects include breast tenderness, nausea, breakthrough bleeding, and headaches, though these often resolve within a few months. COCs are contraindicated for patients with a history of migraines with aura due to an increased risk of stroke. COCs are also associated with an increased risk of venous thromboembolism and hypertension in patients of reproductive age.

A 32-year-old patient presents to the clinic to discuss contraception options. Which of the following items in the patient's history would warrant further investigation prior to prescribing her ethinyl estradiol, norethindrone acetate, and ferrous fumarate combination (Lo-Loestrin Fe)?

The nurse practitioner should further investigate the history component that the patient gave birth 3 months ago and inquire if she is currently breastfeeding Combined oral contraceptive (COC) pills, which contain estrogen and progesterone, are not recommended for patients who are newly breastfeeding, as they may reduce milk supply and impact the quality of milk.Contraceptive methods that contain estrogen should be delayed until at least a month after delivery due to increased risk of venous thromboembolism. Both estrogen and the immediate postpartum period are associated with a higher risk of blood clots, and this risk increases in combination. Progestin-only contraceptive options may be initiated immediately after birth. Progestin-only formulations and devices include pills, implants, injections, and intrauterine devices. Permanent contraception, or tubal ligation, is also an available option for patients who do not wish to become pregnant again.

An 80-year-old woman with a recent history of low-trauma fracture presents to the clinic to review recent DXA scan results. Her T-score value is −1.9, and her 10-year FRAX score is 13%. Which of the following is the best next step in management?

The nurse practitioner should prescribe alendronate (Fosamax) and recommend lifestyle interventions Alendronate is a type of bisphosphonate drug, which is considered first-line treatment for this condition. Typical dosing is 70 mg orally once weekly. Patients should be advised to take the medication first thing in the morning with water and at least 30 minutes prior to the first meal, and they must stay upright for at least 30 minutes after eating to reduce the risk of esophageal side effects.

A female patient presents to the clinic for evaluation due to reports of vaginal burning and irritation. The nurse practitioner performs a wet mount and observes clusters of budding yeast and pseudohyphae via the microscope. Which of the following would be the most appropriate treatment option for this patient?

The treatment of choice for uncomplicated yeast infections is a one-time 150 mg oral dose of fluconazole (Diflucan) Vulvovaginal candidiasis, commonly referred to as a yeast infection, is one of the most common causes of vaginal irritation and discharge. It can be identified by pseudohyphae and clusters of budding yeast under microscopic observation. Patients commonly describe symptoms of chunky white vaginal discharge and intense itching or burning.

A nurse practitioner is assessing a patient with vaginal irritation and foul odor. While analyzing the wet mount, the nurse practitioner identifies cells that appear fuzzy and without sharp edges. Given these findings, which of the following statements should be incorporated into patient teaching?

The wet mount shows clue cells, which are diagnostic for bacterial vaginosis. The first-line treatment for bacterial vaginosis is metronidazole (Flagyl), which can cause a disulfiram-like reaction if alcohol is consumed while taking this or for several days after. It is important to not drink alcohol while taking this medication and for 3 days after completion

The etonogestrel (Nexplanon) implant

This is the best contraception method for this patient. Migraines with aura are not a contraindication for etonogestrel (Nexplanon), and fertility is returned quickly after removal. Any combined contraceptive that has both estrogen and progesterone may worsen migraines with aura and can pose risks such as blood clots and certain cancers, especially in patients over age 35 and those who smoke. A thorough individual health history is essential to choosing a contraceptive method. Medroxyprogesterone acetate (Depo Provera) can cause a delay in fertility anywhere from 15-49 months after the last injection and would be inappropriate for a patient trying to conceive in 1 year. Medroxyprogesterone acetate (Depo Provera) is the only temporary contraceptive method that can cause a marked delay in fertility. The other methods all have a quick return to fertility, with the implantable devices (arm implant and IUDs) being immediate upon removal.

After initial testing, a 42-year-old woman is diagnosed with a trichomoniasis infection. Which of the following treatment regimens is indicated for this infection?

Treatment involves an oral course of metronidazole (Flagyl) for both the patient and the partner can be given in a single or multidose regimen. Both symptomatic and asymptomatic patients with confirmed infection require treatment. Symptoms often include a purulent vaginal discharge with associated burning and pain. However, up to 70% of patients may be asymptomatic, thus emphasizing the importance of screening and treatment. A test of cure is not required if the CDC-recommended treatment regimen is prescribed and completed in full by the patient.

A 29-year-old patient presents for her annual wellness exam. She states she has had several sexual partners over the last year and uses condoms inconsistently. She states she intermittently feels vaginal itching. During her exam, the practitioner notes an erythematous cervix with tiny papillary hemorrhages. This finding is typically indicative of which of the following?

Trichomoniasis Is a sexually transmitted infection caused by the parasite Trichomonas vaginalis. It is one of the most common sexually transmitted infections and may present with vaginal itching and foul-smelling discharge. Many people with trichomoniasis have no symptoms at all, thus emphasizing the importance of screening. A strawberry cervix, which presents as an erythematous cervix with hemorrhages, is a hallmark finding of trichomoniasis. Partners should also be treated to prevent recurrent transmission.

A 70-year-old woman with a surgical history of hysterectomy is interested in starting hormone replacement therapy due to hot flashes and mood lability. The nurse practitioner explains that the initiation of hormone therapy is not recommended due to which of the following adverse effects?

Vascular event Patients who experience menopausal symptoms such as hot flashes, mood lability, and sleep disturbances may be candidates for menopausal hormone therapy (MHT). However, the risk of cardiovascular events, such as myocardial infarction or a cerebrovascular event, is higher in older patients than in their younger counterparts. Initiation of MHT is not recommended for patients over the age of 60. These patients may be candidates for nonhormonal pharmacologic management.

The nurse practitioner previously provided dysmenorrhea care for a 20-year-old patient, who now returns after trying over-the-counter NSAIDs and a combined oral contraceptive for 3 months. She states the pain during her period has not improved, and she is wondering if you could prescribe her something different for the pain. What is the most appropriate response?

When the primary treatment plan for dysmenorrhea fails, a referral to gynecology is the best next step for the patient Primary treatment was appropriate with the use of NSAIDs and a combined oral contraceptive for 3 months. When primary treatment fails, the nurse practitioner should consider endometriosis, leiomyomas, adenomyosis, or pelvic inflammatory disease in the differential diagnosis.

A 20-year-old woman has green vaginal discharge and vaginal irritation. She also reports postcoital bleeding. A speculum exam reveals vaginal erythema, cervical petechiae, and frothy green discharge. Which of the following is the best test to confirm the diagnosis?

a nucleic acid amplification test (NAAT) Trichomoniasis is a sexually transmitted infection caused by the protozoan parasite Trichomonas vaginalis. Typical symptoms are a yellow or green malodorous vaginal discharge, pruritus, irritation, dysuria, and postcoital bleeding. Speculum exam findings include a frothy green discharge, a pH that usually exceeds 6.0, and cervical petechiae, known as a strawberry cervix. In the past, wet-mount microscopy was the preferred diagnostic test for the diagnosis of trichomoniasis. Due to the limited sensitivity of wet-mount microscopy, the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists both recommend a nucleic acid amplification test (NAAT) as the preferred test to diagnose trichomoniasis in women who are symptomatic or at high risk. These tests can be performed on vaginal, cervical, or urine specimens. Testing vaginal discharge with pH and wet-mount microscopy is still appropriate, but a NAAT should be used in conjunction with a negative wet mount in women who are symptomatic or at high risk. However, the presence of motile trichomonads on a wet mount is diagnostic of trichomoniasis. On saline wet-mount microscopy, trichomonads appear as pear-shaped motile protozoa with flagella and a jerking and spinning motion.

A 26-year-old woman presents to the clinic wanting the copper IUD placed. The patient says she has not had intercourse in the last 10 days and does not have any symptoms of an infection. What should the nurse practitioner do first?

a urine pregnancy test should be ordered first Although this patient states that she has not had sexual intercourse in the past week, there is still a chance that she could be pregnant, so a urine pregnancy test should be ordered first. If there are any unknowns, the patient should be provided an hCG quantitative blood test to confirm a negative pregnancy. Placing an IUD in a patient with an unknown pregnancy status can lead to fetal demise or other abnormalities. The copper IUD is a flexible plastic and copper-based T-shaped device that is inserted into the uterus to prevent pregnancy. This type of IUD does not contain hormones. An IUD works by creating a mechanical barrier to implantation, thereby preventing the sperm and egg from joining. It is one of the most effective forms of birth control at 99%. A pelvic exam must first be performed. Then, a tenaculum is used to hold the cervix in place while the uterus is checked for length with a uterine sound or hysterometer. The IUD is then placed through the opening of the cervix into the uterus, and the plastic strings are cut to length.

A 25-year-old man presents to the clinic with the chief concern of unilateral testicular pain. Upon examination, the scrotum is edematous and hot. The patient experiences relief of pain when the testicle is elevated. Which of the following treatments should be ordered for this patient?

administer ceftriaxone (Rocephin) 500 mg IM once and start a course of doxycycline (Vibramycin) Classic exhibited symptoms of epididymitis are unilateral scrotal pain, swelling, and tenderness of the epididymis. Urethritis is not always present. In patients under 35 who are sexually active, epididymitis is most often caused by Chlamydia trachomatis and less commonly by Neisseria gonorrhoeae. In this clinical scenario, cotreatment is required, as no specific pathogen has been confirmed.

A 27-year-old man presents to the office for a follow-up on a sexually transmitted infection screening after recent intercourse with a new partner. The nucleic acid amplification test result is positive for chlamydia. What would be the best treatment option for this patient?

doxycycline (Vibramycin) 100 mg PO twice daily for 7 days

A 53-year-old woman presents with a breast lump she discovered during a self-breast exam. Which of the following physical exam findings is most likely associated with the risk for breast cancer?

fixed, nontender, irregular-shaped singular mass Some characteristics of a breast mass may help distinguish between benign and malignant lesions, even though a clinical breast exam has low predictive power for detecting whether a breast tumor is cancerous. The typical features of a malignant breast mass are a fixed, nontender, irregular-shaped singular mass that is heterogeneous in texture. For patients who present with a palpable breast lump, a detailed history and a thorough clinical breast exam will guide the nurse practitioner's level of concern and assist in determining the next step in management. The first step of a clinical breast exam should be a visual assessment while the patient is seated with their hands on their hips. Nipple discharge, asymmetry, bulging, edema, erythema, or thickening of the skin are all signs that raise concern for malignancy. After inspection, axillary, supraclavicular, and cervical lymph nodes should be palpated while the patient is sitting up. The final step is a palpation of the breasts with the patient in the supine position. In addition to size, consistency, mobility, and tenderness of a palpated breast mass, the distance of the mass from the areola edge and circumferential position on the breast should also be documented. For patients 30 years and older, a diagnostic mammogram is the most appropriate imaging modality. Ultrasonography is the best imaging modality for women under 30 years old.

A 26-year-old woman presents to the office and states she had a positive urine pregnancy test at home. Which hormone do these tests detect?

human chorionic gonadotropin (hCG) Urine and blood pregnancy tests evaluate for the presence of human chorionic gonadotropin (hCG). Levels of hCG are produced by the placenta and increase shortly after implantation. Pregnancy tests are most accurate if taken at the time of the missed period. Markers of hCG can also present in other conditions, such as molar pregnancies and ovarian cancer. Other symptoms of early pregnancy can vary but may include vomiting, nausea, amenorrhea, breast tenderness, urinary frequency, and weight gain.At approximately 8 to 12 weeks gestation, there may be a blue coloring of the cervix and vagina, known as the Chadwick sign. Fetal cardiac activity can typically be detected by 10 to 12 weeks gestation. Transvaginal ultrasound can typically detect the gestational sac or intrauterine fluid collection between 4.5 and 5 weeks, a yolk sac between 5 and 6 weeks, and a fetal pole with cardiac activity between 5.5 and 6 weeks. Diagnosis of pregnancy is based on the detection of hCG in the urine or blood, fetal cardiac activity on Doppler, or identification of pregnancy by ultrasound.

A patient who is 32 weeks pregnant presents to your office after having abnormal lab results at her yearly physical. Her lab results are TSH 0.02 mIU/L, T3 500 ng/dL, and T4 15 ug/dL. Which of the following therapies is indicated?

methimazole (Tapazole) Hyperthyroidism is diagnosed when TSH values are below 0.05 mU/L (normal 0.5-5 mIU/L) and T3 and T4 are elevated. During pregnancy, T3 and total T4 concentrations often exceed 1.5 times the upper limit of normal for nonpregnant patients. Treatment options for hyperthyroidism include radioactive iodine, propylthiouracil (PTU), methimazole (Tapazole), and in some cases, a thyroidectomy. For the first trimester of pregnancy, the medication of choice is PTU, but in the second and third trimesters of pregnancy, it is safe to switch patients to methimazole (Tapazole) instead.

The nurse practitioner is performing a chart review of a new patient who has presented to the clinic for erectile dysfunction. Which of the following comorbidities is not listed as contraindication for the use of (Viagra)?

muscular dystrophy Sildenafil (Viagra) has been shown in studies to potentially reduce respiratory muscle weakness and lung fibrosis. Therefore, patients with muscular dystrophy can use sildenafil (Viagra). Muscular dystrophy causes extensive muscle fiber atrophy resulting in weakness of multiple muscle systems. This loss of strength can lead to difficulty moving and performing everyday tasks. Phosphodiesterase type 5 (PDE5) inhibitors reduce the weakness of the diaphragm muscle and enhance its ability to contract, leading to easier breathing.

A 25-year-old woman presents to the clinic with dysuria, vaginal pruritus, intermenstrual bleeding, and mild lower abdominal pain. The physical examination reveals yellow-green vaginal discharge. Which of the following diagnostic tests should be ordered?

nucleic acid amplification test The nurse practitioner suspects gonorrhea infection. The CDC recommends testing for gonorrhea with a nucleic acid amplification test. Vaginal swabs are preferred for detection in women, and first-catch urine collection is preferred in men. First-catch urine collection can also be performed for women, but it is not as accurate.

A woman at 29 weeks gestation calls the clinic with sudden uterine contractions, vaginal bleeding, and painful abdominal cramping. Which of the following is the most likely diagnosis?

placental abruption Vaginal bleeding, abdominal pain, and uterine contractions are the hallmark signs of placental abruption. The nurse practitioner should instruct the patient to call 911 or be safely transported to the nearest emergency room or labor and delivery unit as quickly as possible. Placental abruption occurs when the placenta separates from the uterus and occurs at or after 20 week gestation. Risk factors include hypertension, physical uterine abnormalities, genetic factors, use of cocaine, history of smoking, and history of placental abruption with previous pregnancies. For patients with a placental abruption with their first pregnancy, the risk of occurrence with future pregnancies increases 93 times. Severe placental abruption is defined as complications in the mother (disseminated intravascular coagulation, shock, organ failure, or death) or fetus (growth restriction, non reassuring fetal status, or death). Treatment includes fetal heart rate monitoring, maternal hemodynamic monitoring, lab monitoring for disseminated intravascular coagulation, and intravenous fluids and blood products, if needed.

acute epididymitis:

posterior scrotal pain and swelling that may be accompanied by dysuria and urinary frequency. Physical findings include tenderness of the epididymis, inflammation of the scrotum, anatomically normal testes, and a positive Prehn sign. In acute epididymitis, pain and swelling are present for < 6 weeks. A urinalysis should be evaluated by microscopy, dipstick test, or Gram stain.

The practitioner is examining the results of a wet mount for a patient suspected to have a vulvovaginal candidiasis infection. Which of the following findings on a wet mount would support this diagnosis?

pseudohyphae Vulvovaginal candidiasis, commonly referred to as a yeast infection, is one of the most common causes of vaginal irritation and discharge. It can be identified by the presence of pseudohyphae, spores, and bud cells on a wet mount. Patients often describe a chunky white vaginal discharge and intense itching.

A 19-year-old man presents to the clinic with heaviness and painless swelling on the right side of his scrotum that has persisted for 3 weeks. An in-office ultrasound shows a solid mass present on the right testicle. Which of the following is the most likely next step in management?

refer the patient for tumor markers The primary differential diagnosis for a patient with a firm, fixed, painless testicular mass is testicular cancer. Since an ultrasound already confirmed a solid mass, the next step in management is to refer the patient for tumor markers, as nurse practitioners will use these levels for staging, prognosis, and a baseline measurement for comparing levels throughout treatment. Testicular cancer can occur in young adults, and new cases in the United States are on the rise in patients aged 20 to 34 years old When a testicular mass is found, the first course of action is an ultrasound to determine the consistency of the mass to rule out other possible diagnoses such as a hydrocele or epididymitis. When a solid mass suspicious for malignancy is visualized, the patient is referred to a specialist, and further testing is completed, including tumor markers and additional imaging to evaluate for staging and metastasis. A discussion about sperm preservation should be had with the patient prior to surgical intervention, especially if the patient is at risk for infertility. Then, a radical orchiectomy is often performed. The only way to definitively diagnose testicular cancer is by examining the histology of tissue obtained from a radical orchiectomy. A biopsy of the mass before removal of the testicle can increase the risk of metastasis into inguinal lymph nodes, and thus it is not performed.

A 32-year-old woman presents to the clinic and reports that she was raped the night prior. Which of the following actions should the nurse practitioner initiate?

refer the patient to the nearest emergency department If a patient discloses a sexual assault, and the assault occurred within the past 5 days, the nurse practitioner is expected to promptly refer the patient to the nearest emergency department. This will ensure that standardized protocol is followed when collecting evidence and reporting information to the proper authorities. This is essential to support the patient's potential desire for legal pursuits. The presentation of a patient who has been raped is immensely varied. Some patients may not initially report an assault, or they may not report it at all. Some patients may choose to report this to their nurse practitioner if asked. The nurse practitioner should reassure the patient that sexual assault is always an act of violence and control and is never deserved or asked for. If an assault or rape is in question, the nurse practitioner does not have to make that determination, as that is left to the court, so reporting to the police should be encouraged. It is not necessary for the nurse practitioner to request specific information about the assault when referring to the emergency department, as retelling the story multiple times can be traumatizing for the patient. If the patient desires to express their situation, the nurse practitioner can attentively listen, documenting emotional responses (e.g., anxious behavior, crying) and exact quotes when possible. It is also important to advise the patient not to shower, wash clothing, brush teeth, or do anything that may eliminate evidence. If 5 days have passed since the assault, medical care can be managed in the clinical setting.

The practitioner is reviewing the Pap smear results for a 30-year-old patient. The report is positive for HPV and atypical squamous cells of undetermined significance. What is the best plan of action for this patient?

referral for a colposcopy In a patient 30 years of age or older, cytology results of atypical squamous cells of undetermined significance (ASC-US) with positive HPV testing warrant referral for a colposcopy for further evaluation. This is the recommendation regardless of HPV subtype. If the patient had a Pap smear that was positive for ASC-US but negative for HPV, repeat Pap screening in 1 year would be recommended. Patients in this age group with a Pap smear negative for ASC-US but positive for HPV types 16 or 18 are also referred for colposcopy.

The nurse practitioner is reviewing Pap smear results for a 21-year-old patient. The report notes that there are atypical squamous cells and cannot exclude high-grade squamous intraepithelial cells. Which of the following is the best plan of action for this patient?

the patient should be referred for a colposcopy When cytology results return as atypical squamous cells that cannot exclude high-grade intraepithelial changes, regardless of age, the patient should be referred for a colposcopy. This is because high-grade changes in the intraepithelial cells can indicate precancerous cells. A colposcopy can visualize the cervix and collect biopsies if needed, which will guide further management.

A woman who is 28 weeks pregnant comes to the clinic for a routine prenatal lab draw. The mother had blood drawn to assess immunity to varicella, but the results came back nonimmune. When would be the best time to give this pregnant patient her varicella vaccine to protect both her, her child at home, and her fetus?

waiting until after the baby has been born Varicella is a live attenuated virus vaccine typically given to children at their 12-month and 4-6-year annual visits. Live vaccines are not safe to administer to pregnant patients, so waiting until after the baby has been born is the safest course of action. Pregnant patients should always be reminded to screen any potential contacts for communicable diseases as they are at a higher risk of complications due to pregnancy. Additionally, varicella is highly communicable, with the common name chickenpox. It is a cutaneous and rarely systemic infection of the varicella-zoster virus. A two-dose treatment regimen is recommended for young children, and girls and women of childbearing age should remain on an effective birth control regimen for 3 months after receiving varicella vaccine dosing.

Overgrowth of squamous epithelial cells?

would be seen on a Pap smear rather than a wet mount and could be a sign of infection, including HPV.