OB- Apex Questions
All of the following are appropriate for pain relief during the first stage of labor except a/an: a) paracervical block b) pudendal block c) paraverterbral sympathetic lumbar block d) epidural block
b) pudendal block **The perineum is innervated by the pudendal nerve, which derives from s2-s4. Therefore, a pudendal block would not be helpful for first stage labor pain as this pain results from T10-L1 stimulation.
A patient requires a forceps delivery. SHe is receing a continuous epidural infusion of 0.125% bup for labor pain. What are the BEST analgesic options for this procedure? (select 2) a) continue current epidural infusion b) pudendal nerve block c) paracervical nerve block d) bolus 3% chloroprocaine in the epidural
b) pudendal block d) bolus 3% chloroprocaine in the epidural
All of the following are consistent with subdural placement of an epidural catheter EXCEPT a/an: a) negative test dose for intrathecal injection b) rapid onset of anesthetic action c) higher than expected spread of LA d) negative test dose for intravascular injection
b) rapid onset of anesthetic action
Compared to a single-shot intrathecal anesthetic, the epidural volume extension technique: a) is more likely to cause hypotension b) uses a smaller initial dose of LA c) is associated with a slower onset d) enhances caudal spread of the LA
b) uses a smaller initial dose of LA
What is the MOST common cause of postpartum hemorrhage? a) placental retention b) uterine atony c) uterine inversion d) cervical laceration
b) uterine atony
A parturient with an epidural catheter in place is schedule for an emergency CS due to variable fetal decelerations. Select the BEST LA to produce surgical anesthesia. a) 0.5% lidocaine b) 0.2% ropivacaine c) 3% 2-chloroprocaine d) 0.75% bupivacaine
c) 3% 2-chloroprocaine
An OB/GYN physician requests an inhalational technique to provide analgesia for her patient's labor pain. Which technique is MOST appropriate to use on the labor and delivery floor? a) 0.5% sevo + 100% O2 administered by the labor and delivery RN b) 50% nitrous oxide + 50% oxygen administered b the labor and delivery RN c) 50% nitrous oxide + 50% oxygen self-admin by the patient d) an anesthesia provider must be present to provide an inhalational agent
c) 50% nitrous oxide + 50% oxygen self-admin by the patient
Which factor is unchanged in the parturient at term? a) HCO3 b) PaCO2 c) Arterial pH d) PaO2
c) Arterial pH
Anesthetic considerations for the use of methergine (ergot alkaloid) include: a) IV administration is safe b) tocolysis c) administration of 0.2 mg d) risk of water intoxication
c) administration of 0.2 mg **0.2 mg is the dose of IM methergine and should ALWAYS be given IM, as IV administration can result in severe hypertension, particularly in the patient with preeclampsia. Methergine is a 2nd line uterotonic drug (it increases contractility) and there is a risk with water intoxication with oxytocin not methergine.
Cardiovascular complications of chronic maternal cocaine abuse include all of the following EXCEPT: a) ephedrine resistant hypotension b) thrombocytopenia c) anemia d) myocardial ischemia
c) anemia
Which drugs do not cross the placenta during pregnancy (select all that apply): a) metoprolol b) magnesium c) glycopyrolate d) insulin e) propofol f) lidocaine g) succinylcholine h) rocuronium i) heparin
c) glycopyrolate d) insulin g) succinylcholine h) rocuronium i) heparin
Three minutes after deliver, a crying newborn has a heart rate of 121 and an SP02 of 62%. What is the MOST appropriate management at this time? a) assisted facemask ventilation with room air b) 100% oxygen via facemask c) observation d) tracheal intubation
c) observation **Immediately after delivery, the normal SP02 is 60%. It should rise to 90% after 10 minutes.
Which analgesic technique is associated with the HIGHEST incidence of fetal bradycardia? a) combined spinal/epidural b) pudendal block c) paracervical block d) paraverterbral lumbar sympathetic block
c) paracervical block
What is the MOST likely diagnosis for a parturient at 32-weeks gestation who presents with painless vaginal bleeding? a) placenta accreta b) abruptio placentae c) placenta previa d) uterine inversion
c) placenta previa
Which condition is BEST treated with intravenous nitroglycerin? a) placenta previa b) polyhydraminos c) retained placental fragments d) prolonged labor
c) retained placental fragments **Nitro will cause uterine relaxation by increasing nitric oxide production.
15 minutes after a patient's epidural was dosed, the patient becomes hypotensive and experiences respiratory arrest. What is MOST likely the etiology? a) epidural cathetar migration b) loss of accessory respiratory muscle strength c) subdural injection d) eclampsia
c) subdural injection **These are symptoms of a total spinal
Which local anesthetic reduces the efficacy of epidural morphine? a) etidocaine b) ropivacaine c) levobupivacaine d) 2-chloroprocaine
d) 2-chloroprocaine **2-chloroprocaine antagonizes mu and kappa receptors in the spinal cord. This reduced the efficacy of epidural morphine. There are NO other local anesthetics that do this.
A pregnant mother has a history of mitral stenosis. When is she at GREATEST risk of hemodynamic compromise? a) second trimester b) third trimester c) 2nd stage of labor d) 3rd stage of labor
d) 3rd stage of labor
What hormones contribute to vascular engorgement and hyperemia in pregnancy? a) progesterone b) estrogen c) relaxin d) all the above
d) all the above
During an emergency CS, the surgeon should make incision immediately after: a) the patient loses conciousness b) mask ventilation is established c) the prep solution is completely dry d) confirmation of ETCO2
d) confirmation of ETCO2
The fetal heart rate monitor shows bradycardia that parallels the rise in intrauterine pressure. This finding is MOST likely the result of a) maternal hypertension b) umbilical cord compression c) fetal acidosis d) fetal head compression
d) fetal head compression
All of the following are appropriate during a cesarean section under general anesthesia EXCEPT: a) datta handle b) 6.0 ETT c) RSI d) nasal airway
d) nasal airway
Anesthetic implications for cesarean section under general anesthesia include: a) administration of a dopamine agonist b) prolonged neonatal respiratory depression c) increased MAC d) rapid sequence induction
d) rapid sequence induction ** Mortality is 17-times higher with a GA.
Which stage of labor begins with the onset of perineal pain? a) latent stage b) active stage c) first stage d) second stage
d) second stage **Full cervical dilation to delivery of the newborn
Match each serum magnesium concentration with its expected clinical effect a) 8 mg/dL b) 15 mg/dL c) 5 mg/dL d) 1 mg/dL 1) seizures 2) drowsiness 3) loss of patellar tendon reflex 4) respiratory depression
8 = loss of patellar tendon reflex (deep tendon reflex) (hypermagnesemia) 15 = respiratory depression (hypermagnesemia) 5 = drowsiness (hypermagnesemia) 1 = seizures (due to hypomagnesemia)
Which arterial blood gas is MOST likely to occur in a pregnant patient's first trimester? a) 7.42/30/101/20 b) 7.33/44/96/19 c) 7.36/36/97/22 d) 7.45/31/85/19
a) 7.42/30/101/20 **progesterone is a respiratory stimulant, increasing minute ventilation up to 50%.
Five minutes following delivery, a newborn has an irregular respiratory rate with a heart rate of 105. He is grimacing, has some flexion in the extremities and has a pink body with blue extremities. Calculate his apgar score.
6 1+2+1+1+1+1
Which surgical procedure carries the GREATEST risk of preterm labor in patient who is 32 weeks gestation? a) appendectomy b) lumpectomy c) ankle ORIF d) AV fistula declotting
a) appendectomy **Ideally surgery should be delayed for 2-6 weeks after delivery. Otherwise, the second trimester is the best time for surgery in the pregnant patient.
A healthy patient is entering the latent phase of labor and requests an epidural. What is the MOST appropriate action at this time? a) approve the request with the consent of the obstetrician b) wait until the patient has been NPO > 2 hours c) wait until the cervix has dilated to 5 cm d) obtain a platelet count, then proceed if > 75,000/uL
a) approve the request with the consent of the obstetrician
Which LA is LEAST likely to undergo fetal ion-trapping? a) chloroprocaine b) bupivacaine c) mepivacaine d) lidocaine
a) chloroprocaine
When is the BEST time to perform non-obstetric surgery on the parturient? a) 1st trimester b) 2nd trimester c) 3rd trimester d) the timing of surgery does not affect fetal outcome
b) 2nd trimester
Uterine blood flow is (select 2) a) 20% of CO b) 700 ml/min c) not autoregulated d) reduced by phenylephrine
b) 700 ml/min c) not autoregulated **UBF is 10% of CO
When administered in maternal circulation, which drugs are MOST likely to affect the fetus? (select 2) a) chloroprocaine b) magnesium c) midazolam d) rocuronium
b) magnesium c) midazolam Chloroprocaine is metabolized by psuedocholinesterase and rocuronium does not cross the placenta.
Side effects of beta agonist therapy for preterm labor include: a) maternal hypoglycemia b) maternal hypokalemia c) fetal hyperglycemia d) fetal bradycardia
b) maternal hypokalemia
Which factors are expected to INCREASE during pregnancy (select 3) a) creatinine clearance b) lower esophageal sphincter tone c) sensitivity to local anesthestics d) MAC e) gastric pH f) urine glucose
a) creatinine clearance c) sensitivity to local anesthetics f) urine glucose **CrCl increases due to increased intravascular volume and cardiac output (Cr/BUN are decreased); urine glucose increases as a result of increased GFR; increased progesterone increases sensitivity to local anesthetics and decreases MAC by 30-40% at 8-12 weeks gestation
Physiologic effects of progesterone during pregnancy include: (select 3) a) decreased MAC b) decreased PaCO2 c) decreased renin d) increased sensitivity to local anesthetics e) increased SVR f) increased lower esophageal sphincter tone
a) decreased MAC b) decreased PaCO2 d) increased sensitivity to local anesthetics
A 32 week parturient presents with painless vaginal bleeding. The MOST likely diagnosis is: a) abruptio placentae b) placenta previa c) uterine rupture d) uterine atony
b) placenta previa
A patient requires an emergent CS. Which of the following is the MOST likely cause for rapid arterial oxygen desaturation during intubation. a) decreased expiratory reserve volume b) increased inspiratory reserve capacity c) increased residual volume d) decreased vital capacity
a) decreased expiratory reserve volume
What is MOST likely cause of EARLY fetal decelerations? a) fetal head compression b) placental insufficiency c) umbilical cord compression d) parasympathetic overactivity
a) fetal head compression
A patient with preeclampsia is receiving a magnesium sulfate infusion. She appears lethargic with swallow respirations and has an irregular pulse. What are the BEST treatments at this time? (select 2) a) furosemide b) calcium gluconate c) potassium chloride d) activated charcoal
a) furosemide b) calcium gluconate
Cardiovascular changes that accompany a normal pregnancy include an increased (select 3) a) heart rate b) systolic blood pressure c) plasma volume d) diastolic blood pressure e) stroke volume f) systemic vascular resistance
a) heart rate e) stroke volume c) plasma volume
P50: a) increases in the mother and decreases in the fetus b) decreases in the mother and increases in the fetus c) remains constant in the mother and decreases in the fetus d) remains constant in the mother and increases in the fetus
a) increases in the mother and decreases in the fetus ** Oxyhgb dissociation curve tells us the tendency of hgb to bind oxygen, and the p50 is the PaO2 where hgb is 50% saturated by oxygen. A higher P50 reflects a right shift and a lower P50 reflects a left shift (right= release left = love)
The second bubble- this is growing into the myometrium and the endometrium
Click on the area that represents placenta increta
An obstetric patient at 33-weeks gestation requires a lap appy. Which drug presents the GREATEST risk to fetal well being a) ketorolac b) succinylcholine c) propofol d) morphine
a) ketorolac **After 1st trimester, NSAIDs can close the ductus arteriosus.
A mother in labor complains of dull and diffuse pain in her abdomen. Choose the statement that best describes her pain (select 2) a) a pudendal nerve block will treat the pain b) afferent pain travels through the hypogastric plexus c) pain is transmitted to the T10-L1 segments of the spinal cord d) the cervix is fully dilated
b) afferent pain travels through the hypogastric plexus c) pain is transmitted to the T10-L1 segments of the spinal cord
All of the following increase the risk of pulmonary aspiration before the onset of labor EXCEPT: a) decreased gastroesophageal barrier pressure b) decreased gastric emptying c) increased gastrin secretion d) increased progesterone production
b) decreased gastric emptying
Which drugs undergo the GREATEST amount of uteroplacental transfer? (select 3) a) rocuronium b) desflurane c) heparin d) lidocaine e) magnesium f) glycopyrrolate
b) desflurane d) lidocaine e) magnesium
A healthy, 40-week parturient requests an epidural for labor pain. She is concerned she won't be able to eat or drink. According to the ASA practice guidelines for obstetric anesthesia, this patient: a) may eat solid food before the epidural is placed b) must stop clear liquids after the epidural is inserted c) can continue to eat and drink until she enters the second stage of labor d) should abstain from eating or drinking until the baby is delivered
a) may eat solid food before the epidural is placed
Which drug is NOT indicated for aspiration prophylaxis for a patient undergoing a c-section with general anesthesia? a) metoclopramide b) glycopyrrolate c) sodium citrate d) ranitidine
b) glycopyrrolate
Diagnostic features of preeclampsia include: (select 2) a) generalized edema b) hypertension c) proteinuria d) seizures
b) hypertension c) proteinuria
Which signs are consistent with a diagnosis of preeclampsia? (select 3) a) seizures b) increased thromboxane c) increased prostacyclin d) proteinuria e) vasoconstriction f) impaired platelet aggregation
b) increased thromboxane e) vasoconstriction d) proteinuria
Match each placental deformity to its description a) placenta previa b) placental percreta c) placental increta d) placental accreta 1) placenta covers the cervical os 2) placenta attaches to the surface of the myometrium 3) placenta invades the myometrium 4) placenta extends beyond the uterus
a) placenta previa = placenta covers cervical OS b) placenta percreta = placenta extends beyond the uterus c) placenta increta = placenta invades the myometrium d) placenta accreta = placenta attaches to the surface of the myometrium Accreta = placenta ATTACHES to the surface of the myometrium Increta = placenta INVADES the myometrium Percreta = placenta extends beyond (PENETRATES) the uterus
According to the American College of Obstetrics and Gynecologists, which findings are predictive of poor fetal status? (select 2) a) sinusoidal pattern b) no late or variable decelerations c) bradycardia without absence of baseline variability d) absent baseline variability
a) sinusoidal pattern d) absent baseline variability
What is the MOST common cause of postpartum hemorrhage? a) uterine atony b) retained placenta c) disseminated intravascular coagulopathy d) uterine inversion
a) uterine atony
T/F. Magnesium will NOT potentiate NMB.
False! Mg potentiates NMBs, which increases the risk of residual weakness.
b) maternal acidosis d) preeclampsia Fetal heart rate tracing shows late decelerations. Maternal acidosis and preeclampsia are causes of late decelerations. Fetal head compression = early decelerations/impending delivery and umbilical cord compression = variable decelerations
Identify the MOST likely conditions that contribute to this fetal pattern (select 2) a) fetal head compression b) maternal acidosis c) umbilical cord compression d) preeclampsia
Early decelerations = head compression **NO RISK OF FETAL HYPOXEMIA
Identify this fetal heart rate variation
Late decelerations = uteroplacental insufficiency ** Risk for fetal hypoxemia- requires urgent assessment of fetal status
Identify this fetal heart rate variation
Variable decelerations = umbilical cord compression **Risk for fetal hypoxemia = requires urgent assessment of fetal status
Identify this fetal heart rate variation
How does the maternal breathing pattern affect fetal oxygenation?
Maternal hyperventilation --> leftward shift of oxyhgb curve --> reduced delivery of O2 to the fetus
T/F. Premature delivery is delivery before 37 weeks gestation or less than 259 days from last menstrual cycle.
True!
T/F. Meperidine possesses local anesthetic properties.
True! **This medication is contraindicated in breastfeeding mothers due to it's active metabolites.
