Lange OBGYN

Given a healthy woman, with no history of abnor-mal Paps and no history of abnormal mammograms, what is the minimum age a female can stop getting Pap smears and mammograms? (A) 65 (B) 68 (C) 70 (D) 72 (E) 75

A (The minimal accepted age for women to stop getting yearly Pap smears and mammograms is 65 years old. A woman must have documented three consecutive normal Pap smears and no history of preinvasive lesions and also no risk factors that would put her at increased risk for cervical cancer. In women of any age who have undergone a hyster-ectomy and who have no history of invasive or pre-invasive cervical disease, Pap smears may be discontinued. Similarly, women may elect to stop having mammography at age 70 years as well. ) (Saslow et al., 2012)

A 28-year-old primigravida presents for routine pre-natal care at 32 weeks' gestation. Her pregnancy has been uneventful and she has been receiving reg-ular prenatal care. At her visit today, the fundal height measurement is 36 cm. Of the possibilities below, which of the following is the LEAST likely cause for the increased fundal height? (A) Fetal macrosomia (B) Fetal position (C) Fibroid uterus (D) Multiple gestation (E) Oligohydramnio

E (Oligohydramnios, diminished amniotic fluid volume, may be associated with intrauterine growth retardation, and would result in a fundal height lower than expected. The fundal height directly cor-relates with gestational age in weeks from 20 to 32 weeks' gestation—for example, at 32 weeks it should measure 32 cm. This measurement, how-ever, is subject to measurement problems. A full bladder can cause an increase of 3 cm and obesity can also distort the correlation.) (Cunningham et al., 2014, pp. 167-193)

A 27-year-old female complains of multiple painful labial ulcerations that appeared about 48 hours ago. A genital swab was obtained and was found to be herpes simplex viral polymerase chain reaction (HSV PCR) positive. Which of the following would be the BEST treatment option for this patient? (A) Acyclovir 400 mg orally, three times a day for 7 days (B) Ceftriaxone 1 g intramuscular, one dose (C) Ciprofloxacin 250 mg orally, twice daily for 5 days (D) Ibuprofen 800 mg orally, three times a day for 3 days (E) Penciclovir 1% topical every two hours for 3 days

A (A positive HSV PCR indicates genital herpes diagnosis and according to the CDC, the recommended treatment is oral therapy 400 mg three times a day for at least 7 days. Topical antivi-ral therapy has been shown to not be as affected as oral therapy for symptomatic ulcers. Ibuprofen can be used for pain control however will not treat the ulcers.) (Workowski & Berman, 2010)

A 52-year-old woman comes in for her annual phys-ical examination. A thorough medical history shows no family history of breast cancer or cervical cancer. Her physical examination reveals no breast skin changes however a firm 1-cm mass can be palpated on the left breast lateral to her areola. Her screening and diagnostic mammogram confirms the mass as suspicious for breast cancer. What is the next best step in the management of this patient? (A) Core needle biopsy (B) Fine-needle aspiration biopsy (C) Open surgical biopsy (D) Lumpectomy (E) Ultrasound

A (Although a fine-needle aspiration biopsy may be a good choice, a core needle biopsy would be a better diagnostic test for this patient secondary to the size of the mass and mammography changes that make this mass suspicious for breast cancer. A large, hollow needle is used to withdraw small cyl-inders or cores of tissue from the abnormal area in the breast. The needle obtains anywhere from three to six samples and is more likely to give a clear result versus a fine-needle aspiration because more tissue is taken to be evaluated by the pathologist. Usually this procedure is performed with ultrasound or fluoroscopy to guide the needle in the correct place, however if the area is easily palpated, those extras are not necessary if the provider feels confi-dent in guiding the needle to the correct location.) (Katz & Dotters, 2012, pp. 301-334)

A 25-year-old nullipara female presents for consul-tation because she suddenly stopped menstruating. On questioning her further it is found that she recently lost 19 lb after starting long-distance running. The MOST appropriate step in her evaluation is measurement of (A) human chorionic gonadotropin (hCG) concentration. (B) serum estradiol-17b concentration. (C) serum prolactin concentration. (D) serum testosterone concentration.' (E) serum thyroid stimulating hormone (TSH) concentration.

A (Although exercise-induced secondary amenor-rhea may seem apparent in this case, it is imperative that pregnancy is ruled out as a cause of the amen-orrhea. All amenorrheic women of reproductive age should be assumed to be pregnant until proven oth-erwise. Therefore, an hCG test is indicated as a first step in the evaluation of this patient. Sudden weight loss and increased physical activity can cause sec-ondary amenorrhea, as can hypothyroidism and hyperprolactinemia. If ordering serum estradiol concentrations, an FSH level should also be ordered. Serum estradiol levels alone are less useful than FSH in deciphering cause of amenorrhea. Decreased estradiol occurs with either hypothalamic-pituitary axis failure or ovarian failure. Decreased FSH indi-cates hypothalamic-pituitary axis failure whereas elevated FSH indicates ovarian failure. Ordering serum testosterone levels should only be considered if the patient has symptoms of PCOS or androgen excess.) (Halvorson, 2012a, pp. 440-459)

A 26-year-old G1P0 at 28 weeks' gestation presents to labor and delivery complaining of low abdominal pain. Her contractions are regular and occur every 15 minutes. The fetal heart rate is 139 bpm and the nonstress test is reassuring. Cervical dilation is 1 cm with no effacement. Patient denies any fluid loss via the vagina. Which of the following medica-tions should be administered next?(A) Betamethasone (B) Magnesium sulfate (C) Nifedipine (D) Ritodrine (E) Terbutaline

A (Corticosteroids accelerate lung maturation and are given to expectant mothers who are less than 34 weeks' gestation and are in preterm labor. Some clinicians believe it is appropriate to use tocolytics to stop preterm contractions, but this is controver-sial. Tocolytics may temporarily stop contractions, but they do not consistently prevent preterm labor and they carry a significant risk. Examples of toco-lytics are terbutaline, magnesium sulfate, ritodrine, and nifedipine. In general, if tocolytics are given they should be given with corticosteroids and gen-erally not after 34 weeks.) (Cunningham et al., 2014, pp. 829-861)

A 25-year-old nulliparous woman complains of dys-menorrhea that has become progressively worse over the past 2 years. Her pain is described as a constant, aching pain. It begins 2 to 7 days prior to onset of bleeding and does not subside until the menstrual flow decreases. In addition, she com-plains of pain with intercourse. She has never been pregnant and uses condoms and foam for contraception. Which of the following is the BEST way to confirm the most likely diagnosis definitively? (A) Laparoscopy (B) MRI (C) Pelvic examination (D) Pelvic ultrasound (E) Trial of prostaglandin synthetase inhibitors

A (Diagnostic laparoscopy is the only definitive way to diagnose endometriosis. Ultrasound and MRI may be helpful in the diagnostic work-up, but laparoscopy is the most certain method of diagnosing endometri-osis). (Beshay & Carr, 2012, pp. 281-303)

A 15-year-old female presents to the local health department concerned about several pruritic fleshy raised lesions on her labia. The patient is diagnosed with genital warts upon examination. She is counse-led on the low-risk human papillomavirus (HPV) types and the rare association with cancer. Which of the following subtypes of HPV was she most likely exposed to? (A) 6 and 11 (B) 11, 12, and 73 (C) 31 and 58 (D) 22 and 78 (E) 39 and 82

A (Low-risk human papillomavirus types 6 and 11 cause almost all genital warts. Although they are very prevalent, they are not associated with malig-nancy or neoplasia.The HR HPV types 16, 18, 31, 33, 35, 45, and 58 are associated with 95% of all cervical cancers worldwide. Gardasil, a recombi-nant quadrivalent HPV vaccine is for prophylactic protection from HPV types 6, 11, 16, and 18.) (Griffith & Werner, 2012, pp. 730-768)

A 25-year-old G1P1 presents to the clinic for her annual examination. She has no history of abnormal Pap smears, but the results from today's test show low-grade squamous intraepithelial lesions (LSIL). Which of the following is the BEST option for what should be done next? (A) Colposcopy (B) HPV testing (C) Recheck Pap in 1 year (D) Repeat Pap smear in 4 to 6 months, using traditional slide method (E) Repeat Pap smear in 4 to 6 months, using liquid-based cytology

A (On the basis of the 2012 Consensus Guidelines for the Management of Women with cervical cyto-logical abnormalities, it is recommended that col-poscopy be done following LSIL on Pap smears. Viewing the cervix and its transformation zone with 10-20× magnification of colposcopy allows for visual assessment. Two solutions are used to further enhance visualization and determination of normal from abnormal tissue. When a dilute solution of acetic acid is applied to the cervix, abnormal areas will look white. After painting the cervix with Lugol solution (a strong iodine solution), the normal squamous epithelial will take on the stain whereas the abnormal tissue will not. All abnormal-appear-ing tissue is biopsied.) (Griffith & Werner, 2012, pp. 730-768)

A 58-year-old female presents to clinic complaining of a pruritic bump she found on her labia. She has not had a pelvic examination in 10 years since her vaginal hysterectomy. On exam, there is a 1-cm irregularly shaped raised brown lesion on her left labia. What is the BEST initial intervention for this patient?(A) Biopsy of lesion (B) Oral prednisone (C) Pelvic MRI (D) Topical corticosteroids (E) Vaginal estrogen therapy

A (The irregular lesion on the patient's vulva is questionable for vulvar intraepithelial neoplasia or vulvar cancer. Patients may be without symptoms or complain of pruritis or burning. Raised brown, red, pink, white, or gray lesions of various colors may be present. Tests to diagnose include colpos-copy and biopsy of lesion. Treatment depends on the degree of the disease, sometimes requiring sur-gical or laser removal. Patients should have regular follow-ups with a healthcare provider and self-vul-var examinations should be recommended monthly. The human papillomavirus (HPV) has been shown to increase risk of VIN and vulvar cancer. )(Edge et al., 2010, pp. 379-381)

A 27-year-old G3P3 presents to an outpatient clinic for her wellness examination. Last year her Pap smear was normal. This year, however, her Pap results indicate atypical squamous cells of unde-termined significance (ASCUS) and the reflex HPV testing results show high-risk (HR) HPV. What is the most appropriate next step in her evaluation? (A) Colposcopy (B) Endometrial biopsy (C) Loop electrosurgical excision procedure (LEEP) (D) Repeat cytology at 6 and 12 months (E) Repeat reflex HPV testing

A (The most appropriate evaluation of this patient is for her to be referred for a colposcopy. A Pap smear is a medical consultation that interprets a lab-oratory test. The interpretation is not a diagnosis. The final diagnosis is made in conjunction with clinical and often histological data. In this patient, it would be inappropriate to repeat the HPV test or repeat the Pap smear. The 2012 ASCCP guidelines for the management of abnormal Pap smears rec-ommend that following the results of atypical cells of undetermined significance (ASCUS), there are three evaluation possibilities: HPV DNA testing, repeat cytology at 6 and 12 months, and colpos-copy. If either the HPV testing or the repeat cytol-ogy is abnormal, then immediate referral for colposcopy is recommended. ASCUS has about a 5% chance of progressing to cervical intraepithelial neoplasia (CIN) 2 or 3. ) (Griffith & Werner, 2012, pp. 730-768)

A 27-year-old female, 38 weeks' gestation presents to the clinic complaining of abdominal cramping for the past 2 hours and spontaneous rupture of membranes. Upon pelvic examination, cervix is dilated to 7 cm. After 4 hours of active labor, the external fetal monitor shows several decelerations and fetal distress is a major concern. What is the BEST course of action for this patient? (A) Immediate cesarean delivery (B) Reposition patient to left lateral decubitus (C) Start intravenous oxytocin (D) Start an epidural (E) Wait until she has dilated to 10 cm for vaginal delivery

A (The patient is considered full term and signs of labor have started with spontaneous rupture of mem-branes. The patient has not completed stage one of labor since she is only dilated to 7 cm and there is a concern for her failure to progress. The most common cause of fetal distress is lack of oxygen to the baby, which can cause fetal brain injury. When fetal monitoring detects decelerations or decrease in fetal heart rate below normal levels, an emergency cesarean should be considered the most appropriate next step. Waiting until she has dilated to 10 cm and starting IV Pitocin may cause increased fetal dis-tress. Starting an epidural can slow down labor and delivery of baby is of utmost importance with decel-erations on fetal monitoring. Changing the mother's position may help, however ACOG recommends quick decisions within 30 minutes to prevent trauma to mother and baby). (Cunningham et al., 2014, pp. 473-503)

A 40-year-old G2P2 complains of postcoital bleed-ing. Her last Pap smear was 15 years ago. On exam-ination, she had a friable lesion on her cervix and her cytology demonstrates squamous cell carcinoma. At this point, the MOST appropriate step in this patient's management is which of the following? (A) Biopsy visualized lesion and refer patient for gynecologic consult (B) Colposcopy with endocervical curettage and directed biopsy (C) Loop electrosurgical excision procedure (LEEP) or cervical conization (D) Radical hysterectomy and radiation therapy (E) Repeat Pap smear in 4 to 6 months

A (There is no generalized clinical picture of cer-vical carcinoma, but there are two symptoms often associated with it. They are postcoital bleeding and abnormal uterine bleeding. The average age at diag-nosis is 50. Lesions on the cervix that should be considered for immediate biopsy include new exo-phytic, friable, or bleeding lesions. In this patient, the lesion should have been biopsied at initial exam-ination and this would have helped to make the diagnosis. When lesions are visualized and the biopsy confirms carcinoma, no colposcopic assess-ment is needed. This patient should definitely not wait 4 to 6 months for a repeat Pap smear. The gynecologic oncologist should stage the cancer and decide on appropriate therapy.) (Richardson, 2012, pp. 769-792)

At 8 weeks' gestation, a 24-year-old primipara was seen a week prior complaining of vaginal bleeding and lower abdominal cramping. Her β-hCG level was 1,000 mIU/mL at that time. Today, she has no abdominal pain or evidence of tissue passed per vagina. Transvaginal ultrasound (TVUS) shows no adnexal masses as well as no intrauterine preg-nancy. Her repeat β-hCG level is 1,100 mIU/mL. What can be concluded from this information? (A) The patient has a pregnancy that is nonviable but its location is unknown. (B) She has had a spontaneous abortion and must have a dilation & curettage. (C) The hCG level needs to be repeated in 48 hours for more information on viability.(D) This is definitely an ectopic pregnancy. (E) This is a molar pregnancy.

A (This is a nonviable pregnancy, but whether or not the pregnancy was located intrauterine or ectopic is not something that can be concluded with the data presented. Because there is a plateau in the hCG level after 1 week (48 hours is usually suffi-cient), the pregnancy is nonviable. The hCG level need not be repeated at this point. TVUS appears to demonstrate no visualized products of conception. It should be noted, however, that this could represent an incomplete abortion. An ectopic pregnancy cannot be ruled in or out yet. If β-hCG levels are 1,500 mIU/mL and the uterus is empty, a live uter-ine pregnancy is very unlikely. When β-hCG is less than 1,500 IU/L and an ectopic pregnancy is not seen, progesterone level needs to be determined. If the progesterone level is greater than 25 ng/mL then an ectopic pregnancy is unlikely. At this point, a D&C should be considered. The low hCG levels and lack of findings on ultrasound (e.g., "snow-storm" appearance) would help rule out a molar pregnancy.) (Cunningham et al., 2014, pp. 167-193)

A 50-year-old postmenopausal woman presents to the clinic complaining of vulvar pruritis for the past year. Upon examination, the patient has whitening patches of her vulvar skin in the shape of a figure eight down to her anus. Which of the following is the best course of treatment for this patient? (A) Clobetasol topical to area twice daily for 14 days (B) Miconazole topical to area twice daily for 14 days (C) Oral conjugated estrogens daily (D) Prednisone 5 mg orally, twice daily for 14 days (E) Vaginal estrogen therapy daily

A (This patient has lichen sclerosis and can be iden-tified on examination with the classic figure eight white patch around the vulvar skin and down to the anus. A biopsy can also be performed for diagnosis. Treatment should include topical clobetasol propi-onate 0.05% ointment twice daily for 14 weeks then daily thereafter for at least 12 weeks. Other treat-ments should include avoiding skin irritants and well-ventilated clothing. In all patients with lichen sclerosis, regular follow-up is needed because of the increased risk of developing squamous cell carci-noma). (Bornstein, 2013, pp. 620-645)

An 18-year-old female college student presents to the emergency department stating that she was sexually assaulted 2 hours earlier. Appropriate INITIAL med-ical professional intervention for the patient should be (A) provide acute medical care. (B) prophylaxis therapy for sexually transmitted infections and pregnancy. (C) psychology consult. (D) referral to counseling services. (E) reporting to local authorities.

A (Unfortunately, one in six women in America will be a victim of sexual assault in their lifetime and will often present to the emergency room for help. As a medical provider, the initial point of con-tact is to ensure the patient is stable and provide acute medical care. Often victims have been beaten or injured. Although providing prophylaxis therapy for sexually transmitted infections and prevention of pregnancy be offered, this would not be the first step in treating this patient. A consult with the local sexual assault agency should be made and it is up to the victim to report the crime unless child abuse or human trafficking is suspected.) (Ettinger & Gambone, 2010, p. 324)

A 22-year-old nulliparous woman presents with a chief complaint of heavy, irregular menstrual bleeding over the past year. Patient has a body mass index (BMI) of 35 with hirsutism, acne and border-line hypertension. Patient denies any vaginal dry-ness, mood changes, hot flashes, hot or cold intolerance, diarrhea, or heart palpitations. She is currently not sexually active. Which of the follow-ing would be the BEST diagnostic tool for the most likely diagnosis? (A) CT scan of abdomen and pelvis (B) History and physical examination (C) Labs—estradiol, luteinizing hormone, and follicle stimulating hormone (D) Transvaginal ultrasound (E) Wet mount

B (Polycystic ovarian syndrome (PCOS) is sug-gested by her being moderately overweight and having hirsutism and acne. Eighty percent to 90% of the diagnosis can be made from the medical his-tory. Clinically, the most common signs of PCOS are hirsutism (90%), menstrual irregularity (90%), and infertility (75%).) (Wilson, 2012, pp. 460-480)

A 28-year-old female has had several recurrent spontaneous abortions secondary to an incompetent cervix. At her most recent office visit, her preg-nancy test was positive and a viable pregnancy was seen on ultrasound at 8 weeks and 3 days. Which of the following is the BEST way to avoid a miscar-riage or a premature birth for this patient? (A) Bed rest (B) Cerclage (C) Magnesium sulfate (D) Pessary (E) Terbutaline

B (Although all the methods listed (bed rest, devices, and pharmacologic agents and surgery) work to some degree to treat an incompetent cervix, the generally accepted treatment is surgical. A cer-vical cerclage is a suture or bands that are placed surgically on the cervix to keep it closed prior to delivery. The sutures are removed after fetal matu-rity has been achieved (about 37 weeks). Labor and delivery occurs rapidly after the removal of the cer-clage. The terbutaline and magnesium sulfate are pharmacologic agents used for the medical manage-ment of preterm labor with a competent cervix. ) (Cunningham et al., 2014, pp. 167-193)

A 26-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical exam-ination and general laboratory profile showed no abnormalities. Which of the following is the MOST effective treatment choice for this patient? (A) Alprazolam (Xanax) (B) Fluoxetine (Prozac) (C) Ibuprofen (D) Progestin-only oral contraceptive (E) Spironolactone (Aldactone)

B (Although approximately 40% of menstruating women experience one or more of the cluster of physical, emotional, or behavioral symptoms asso-ciated with the luteal phase of the menstrual cycle (premenstrual syndrome or premenstrual tension), a small percentage have symptoms so severe that they meet the DMS-V diagnosis of premenstrual dysphoric disorder (PMDD). For the treatment of mild to moderate symptoms, lifestyle and dietary changes may be effective. Therefore, a trial of regular aerobic exercise, decrease in caffeine and alcohol intake, 1,200 mg of dietary calcium with 800 IU of vitamin D per day, and eating complex carbohydrates as opposed to simple sugars could be initiated. For patients whose symptoms affect jobs and relationships, it is warranted to prescribe sero-tonin reuptake inhibitors such as fluoxetine. Fluoxetine 20 mg can be taken daily or only pre-menstrually.) (MacKay & Woo, 2014, pp. 726-758)

A 21-year-old female presents to the family plan-ning clinic at her local health department for an annual examination. Patient is currently sexually active and has had three new partners over the past year. She uses oral contraceptives, however rarely uses condoms during her sexual encounters. Other than increased vaginal discharge, patient is asymp-tomatic. Speculum examination shows a mildly fri-able, erythematous cervix with no active discharge. Pregnancy test is negative and no cervical motion tenderness or adnexal masses. Two weeks later, her vaginal nucleic acid amplification test (NAAT) comes back positive. What is the MOST likely path-ogen causing the positive test? (A) Candida albicans (B) Chlamydia trachomatis (C) Escherichia coli (D) Herpes simplex virus (E) Neisseria gonorrhoeae

B (Chlamydial genital infections are the most fre-quently diagnosed sexually transmitted infection in the United States. More than 50% of the time, the patient is asymptomatic. In women, the infection tends to occur in the endocervical canal with symp-toms that may include intramenstrual or postcoital bleeding, an odorless mucoid vaginal discharge, pelvic pain, or dysuria. Untreated or inadequately treated infections can lead to a more serious prob-lem such as pelvic inflammatory disease, ectopic pregnancy, and infertility. ) (Centers for Disease Control & Prevention, 2014)

A 30-year-old woman presents with bilateral breast pain and nodularity. The tenderness and size of the nodules increase premenstrually. She has no family history of breast cancer. On physical examination, multiple tender "rope-like" nodules are palpated. There is no dominant mass and the lymph nodes are not palpable. After reassuring the patient regarding cancer probability, which of the following is recom-mended for INITIAL management? (A) 200-mg danazol daily during luteal phase of menses (B) Decreasing use of caffeine and tobacco (C) Fine-needle aspiration to determine atypia (D) Galactography to determine if lesions are focal (E) Ultrasound for definitive diagnosis

B (Cyclic mastalgia in usually managed sympto-matically and requires no evaluation. Fibrocystic breast changes are the most common type of benign breast mass. Clinically they are often described as "rope-like," meaning they have the characteristic on palpation of feeling like a coiled rope. There is often diffuse nodularity, although solitary cysts may range in size. Also, the size of an individual cyst may fluctuate throughout the menstrual cycle. Pain is the most common presenting symptom of fibro-cystic breast change. Often, women will respond to dietary changes, such as decreased caffeine and/or tobacco. Danazol as well as bromocriptine, tamox-ifen, and GnRH agonists are usually reserved for women with the most severe symptoms.)

A 23-year-old female, G1P0, at 12 weeks' gestation presents for routine prenatal care with a normal medical history. Which of the following should be done at today's visit? (A) 3 hour glucose tolerance test after 100 g oral glucose load (B) Complete blood count, HIV testing, and urinalysis (C) Chorionic villus sampling (D) Trichomonas vaginalis screening (E) X-ray pelvimetry

B (During the first trimester, several diagnostic tests are routine. For this patient with a normal med-ical history and no risk factors, a CBC, HIV testing and urinalysis is performed at the first obstetrics appointment. A CBC is performed to evaluate for any anemias or platelet disorders that would mean a blood clotting disorder. HIV testing is important to diagnosis and treat to improve the health of the mother and dramatically reduce the transmission of HIV from mother to fetus. A urinalysis should be performed to evaluate for glycosuria, proteinuria and hematuria which would all be signs of possible complications during pregnancy. If the patient has increased risk factors such as multiple sexual part-ners, other sexually transmitted infections should be screened. A 3-hour glucose tolerance test should only be performed if the patient fails the 1 hour glucose tolerance test between 26 and 28 weeks, so for this patient, it is too early for any glucose toler-ance testing. Chorionic villus sampling is per-formed to detect chromosomal abnormalities and genetic disorders, and is usually done between 10 and 12 weeks' gestation, but is not routine in a normal pregnancy.) (ACOG Committee on Obstetric Practice, 2012, pp. 105-168)

A healthy 20-year-old woman is using a low-dose triphasic contraceptive pill for birth control. She experiences breakthrough bleeding during the third week of each cycle for the past few months. Her pregnancy test is negative. The physical examination is normal. There is no infection or thyroid problem. The patient desires to stay on oral contraceptives. What is the BEST way to manage her therapy? (A) Continue current oral contraceptive pill (OCP), but add extra estrogen during the third week (B) Change to a pill with a higher progestin component (C) Prescribe a progestin-only pill (D) Reassure her and have her return in 1 month (E) Switch to a pill with a higher estrogenic component

B (During the initial 3 months of oral contraceptive use, breakthrough bleeding is a common side effect and can be best managed by encouraging the patient to continue on the contraceptives. After initiating therapy, when breakthrough bleeding occurs during the third week of the cycle, it is due to a lack of progestin and is best managed by changing to a pill with a higher progestin component.) (Beckman et al., 2014, pp. 237-252)

A 34-year-old African-American female presents to the office concerned about worsening lower abdom-inal bloating, pelvic pressure, mild deep dyspareu-nia, and heavy menstrual bleeding. On pelvic examination, a 20-week size uterus is palpated and transvaginal ultrasound confirms a large leiomy-oma. The patient and her husband have been trying to conceive over the past year and have been unsuc-cessful. What treatment option would be the BEST course for this patient? (A) Endometrial ablation (B) Laparoscopic-assisted myomectomy (C) Leuprolide acetate (Lupron Depot) (D) Oral contraceptives (E) Total abdominal hysterectomy

B (For women desiring to preserve their fertility, myomectomy is an option if the number and size of the fibroids is limited. Surgical approach depends on the location and a magnetic resonance imaging (MRI) can localize and estimate the volume of the myoma.) (Nelson & Gambone, 2010, p. 244)

At 16 weeks' gestation, a 19-year-old G1P0 Asian patient presents with a complaint of vaginal bleed-ing. She also has been experiencing severe nausea and vomiting. Her quantitative β-hCG is much higher than expected and her fundal height is approximately at 18- to 20-week size. Although she denies a past history of hypertension, her blood pres-sure is 140/90 mm Hg. No fetal heart sounds can be heard on Doppler and there is no sign of a fetus on ultrasound. What is the MOST likely diagnosis? (A) Fetal demise at 16 weeks (B) Hydatidiform mole (C) Incomplete abortion (D) Threatened abortion (E) Twin gestation

B (Hydatidiform mole is one component of gesta-tional trophoblastic neoplasm (GTN). Moles occur in a gestation in which there is a proliferation of trophoblastic tissue. It can be a complete mole, in which there is no sign of a fetus, or a partial mole, in which the fetus may be viable, or there are find-ings consistent with a nonviable fetus. Young preg-nant women (20) and older (>40) reproductive ages have increased incidence as do patients with Asian, Latino, or Filipino ethnicity. The most common symptom of hydatidiform mole is several episodes of vaginal bleeding. A size-to-dates discrepancy also is common. Severe nausea and vomiting may occur as well. When signs and symptoms of preec-lampsia present earlier than 24 weeks' gestation, molar pregnancy should be high on the differential. The trophoblast is responsible for production of human chorionic gonadotropin (hCG); therefore, the levels of β-hCG in the serum are greater than expected for the weeks of gestation. Ultrasound demonstrates a characteristic "snowstorm" appear-ance and is the best means of diagnosing a mole. An incomplete abortion usually occurs prior to 12 to 14 weeks and is often characterized by a decreasing β-hCG level. A fetal demise at 16 weeks would also have decreasing β-hCG levels and would not be associated with hypertension. In twin gestation, there would be a higher level of β-hCG and a larger fundal height, but at 16 weeks, fetal heart tones should be heard.) (Schorge, 2012, pp. 898-917)

A 36-year-old woman at 22 weeks' gestation pre-sents for her regular check-up. Her hemoglobin level is 10.8 g/dL. Which of the following state-ments regarding this patient's hemoglobin level is TRUE? (A) This patient has iron deficiency anemia (B) This patient has physiologic anemia of pregnancy, no further work-up necessary (C) This patient should receive ferrous sulfate 300 mg 1-2 × a day (D) Repeat hemoglobin in 2 months when more accurate reading can be obtained (E) A complete evaluation of the anemia, including serum ferritin, needs to be done

B (In healthy pregnant women who are not defi-cient in iron or folate, a modest fall in hemoglobin levels at this point of gestation is usually due to the relative greater expansion of plasma volume compared with the increase in hemoglobin mass and red blood cell volume that accompanies normal pregnancy. In healthy nonpregnant women, anemia is defined as a hemoglobin of less than 12 g/dL. During pregnancy, a patient is not considered anemic until the hemoglobin falls below 10 g/dL. In the first trimester and at term, the hemoglobin level for most healthy women is 11 g/dL or greater. During the second trimester, women experience a nadir in their hemoglobin between 22 and 24 weeks and anemia is not considered until the hemoglobin is 10.5 g/dL or less.) (Cunningham et al., 2014, pp. 167-193)

A 32-year-old woman, G2P1, at 35 weeks' gesta-tion presents with a complaint of intermittent bleed-ing over the past week; however, she has had no evident pain or cramping. Upon physical examina-tion, fetal heart rate is noted to be normal. These clinical characteristics are MOST consistent with which of the following? (A) Placental abruption (B) Placenta previa (C) Premature labor with bloody mucous discharge (D) Premature rupture of membranes (E) Vasa previa

B (Placenta previa can be distinguished from abrup-tio placentae by many factors. Placenta previa is most commonly characterized by painless hemor-rhage, which usually does not present until the end of the second trimester or later. No abdominal dis-comfort, a normal FHR, and no significant maternal history are usually associated with the problem. Abruptio placentae, on the other hand, is associated with severe pain, abnormal FHR, usually continuous bleeding, and associated with a history in the mother such as cocaine use, abdominal trauma, maternal hypertension, multiple gestations, and polyhydram-nios. In this case, one will need to rule out early labor (accompanying contractions, bloody mucus discharge), coagulopathy, hemorrhoids, vasa previa, cervical or vaginal lesion, or trauma. Vasa previa also occurs late in pregnancy, with vaginal bleeding occurring concomitantly with rupture of mem-branes. Vasa previa occurs when umbilical cord blood vessels transverse the membranes and cross the cervical os below the fetus. Fetal distress will also accompany vasa previa because the blood loss will be fetal; it requires immediate delivery and is accompanied by a high rate of fetal death.) (Cunningham et al., 2014, pp. 780-828)

A 32-year-old woman, G2P1, with gestational dia-betes is delivering at 39 weeks' gestation. The fetus appears to be about 4,100 g. The woman has expe-rienced 5 hours of stage 1 labor and currently is in her second hour of stage 2 labor. The head is deliv-ering but the shoulders are not. Which of the follow-ing descriptions includes the BEST option for delivering this infant? (A) Flexing of the mother's thighs, pitocin augmentation, and suprapubic pressure (B) Flexing of the mother's thighs, suprapubic pressure, and cutting an episiotomy (C) Elevation of the mother's legs, suprapubic pressure, and oxygen for the mother (D) No elevation of the mother's legs, pitocin, and fundal pressure (E) No elevation of the mother's legs, suprapubic pressure, and cutting an episiotomy

B (Shoulder dystocia is a complication associated with macrosomia. Although there is no evidence that any one maneuver is superior to another in releasing an impacted shoulder or reducing the chance of injury, American College of Obstetricians and Gynecologists guidelines recommend perfor-mance of the McRoberts maneuver, as described by choice B, as a reasonable initial approach. Fundal pressure should never be attempted). (Cunningham et al., 2014, pp. 433-454)

A 27-year-old G1P0 presents to labor and delivery with progressively severe and frequent contractions over the past 10 hours. Her contractions are lasting about 50 seconds with 4 minutes in between each contraction. Cervical examination shows dilation to 6 cm with 75% effacement. The stage of labor for this patient would be assessed as (A) first stage, latent phase.(B) first stage, active phase.(C) first stage, transition phase. (D) second stage. (E) third stage.

B (The first stage of labor is divided into two stages: latent and active. The latent stage refers to cervical effacement and early dilation. The active phase occurs when dilation has reached 3 to 4 cm or greater. The second stage of labor begins when cervical dilation is complete and ends with delivery of the infant. The third stage of labor begins after the infant is delivered and ends with placental expulsion. )(Cunningham et al., 2014, pp. 433-454)

A 47-year-old female presents to the clinic con-cerned about a growing mass on her left labia that is now causing discomfort while sitting. Patient denies any fever, chills, or vaginal discharge. On physical examination, a 3-cm fluctuant mass is pal-pated at the 7 o'clock position. Her BEST course of treatment would be which of the following? (A) Amoxicillin/clavulanate (Augmentin) 875 mg orally, twice daily for 7 days (B) Catheter drainage (C) Cephalexin (Keflex) 500 mg orally, three times daily for 7 days (D) Conservative management with warm compress (E) Surgical removal

B (The mass on the patient's left labia would be diagnosed as a Bartholin cyst and is the most common vulvovaginal tumor. They are mostly clin-ically diagnosed by history and physical. Since she is symptomatic and the size of the cyst is greater than 3 cm treatment with a catheter insertion and drainage would be the most appropriate course of action at this time and can be performed in the office. If abscess is a concern, adjunct therapy with broad-spectrum antibiotics should also be imple-mented. Surgical intervention should only be an option for recurrent Bartholin cysts). (Bornstein, 2013, pp. 620-645)

A 25-year-old female at 10 weeks' gestation pre-sents to an outpatient clinic concerned about vagi-nal bleeding and passing pieces of tissue. Which of the following is the most likely etiology of her spontaneous abortion? (A) An incompetent cervix (B) Chromosomal anomalies (C) Inadequate progesterone (D) Maternal drug abuse (E) The presence of maternal lupus anticoagulant

B (The most common cause of spontaneous abortion in the first 12 weeks of pregnancy is chromosomal anomalies (accounting for about half of abortions). Maternal lupus anticoagulant, incompetent cervix, maternal tobacco abuse, and inadequate progesterone during the luteal phase can also be associated with early abortion. Maternal disease is more likely to be responsible in second trimester miscarriage. ) (Cunningham et al., 2014, pp. 350-376)

A 47-year-old G3P3 woman comes into the office complaining of heavy, painful, and irregular men-strual bleeding that has been going on for the past 6 months to a year. She has not been sexually active for the past year. On physical examination, her uterus is estimated to be the size of a uterus at 12 weeks' gestation. Pelvic ultrasound confirms the presence of a leiomyoma. Her hematocrit is 29%, mean corpuscular volume (MCV) is 68 fL, and serum ferritin is 10 g/L. What should be the first-line therapy? (A) Ablation therapy (B) Depot methodroxyprogesterone acetate (Depo-Provera) (C) Hysterectomy (D) Myomectomy of leiomyoma (E) Oral contraceptive therapy in standard doses

B (This patient has a leiomyoma of the uterus (or fibroid tumors), which is the most common benign neoplasm, but she is also significantly anemic. The labs suggest iron deficiency anemia. It is important to control her bleeding and treat her anemia prior to surgery. The heavy bleeding that typically accom-panies fibroid tumors can be minimized by using intermittent progestin supplementation (depot methodroxyprogesterone acetate 150 mg IM every 28 days) and/or prostaglandin synthetase inhibitors. In general, the size of the mass can be decreased and the bleeding can be lessened, but the only cura-tive treatment is a myomectomy or hysterectomy.) (MacKay & Woo, 2014, pp. 726-775)

A 20-year-old nulligravida presents with pelvic pain and irregular menstrual bleeding. She denies sexual activity, and her β-hCG urine test is negative. She has never been on oral contraceptives. On pelvic examination, unilateral tenderness on the left side and a palpable cystic mass approximately 4 to 5 cm in size are present. The MOST likely diagnosis is (A) choriocarcinoma. (B) ectopic pregnancy .(C) functional ovarian cyst.(D) molar pregnancy. (E) sarcoma.

C (A functional ovarian cyst is a much more likely diagnosis than any of the others listed. A follicular cyst develops when an ovarian follicle fails to rup-ture. The granulosa cells lining the cyst continue to enlarge and fluid continues to accumulate. Symptoms associated with a functional ovarian cyst include mild to moderate unilateral pain and alter-ation in the menstrual cycle. On occasion, rupture of the follicular cyst causes acute pelvic pain and may need laparoscopic surgery for complete evalu-ation. In most cases, pain control for 4 to 5 days is what is indicated as well as the consideration of contraception to suppress future ovarian cyst forma-tion.) (Heinzman & Hoffman, 2012, pp. 246-280

A 32-year-old nulliparous woman is seeking con-traceptive advice. She is in a monogamous relation-ship and is a nonsmoker and has a history of one ectopic pregnancy 5 years ago. She wishes to con-sider childbearing in the future. Her history includes mild, well-controlled hypertension, and frequent urinary tract infections. Which one of the following contraceptive options would be contraindicated? (A) Condoms and spermicide (B) Diaphragm (C) Intrauterine device (D) Low-dose combined oral contraceptive (E) Progesterone-only oral contraceptive

C (A prior tubal pregnancy contraindicates IUD use. Condoms and spermicides are free of hormonal side effects and, if used in combination, are reason-ably effective. This patient's hypertension is mild and controlled and unlikely to be negatively affected by either low-dose or progesterone-only oral con-traceptives. Although there can be an association between urinary tract infections and diaphragm use in susceptible women, this would not be an absolute contraindication to diaphragm use. )(Cunningham & Stuart, 2012, pp. 132-169)

A 44-year-old female presents for cancer testing after her mother was recently diagnosed with breast cancer 6 months ago. Her laboratory work confirms a positive result for BRCA1 gene mutation. Which of the following types of cancer is she at MOST increased risk for developing? (A) Cervical cancer (B) Endometrial cancer (C) Ovarian cancer (D) Vaginal cancer (E) Vulvar cancer

C (About 1.4% of women will develop ovarian cancer sometime during their lives. However, 39% of women who inherit a harmful BRCA1 mutation will develop ovarian cancer. This patient is also at increased risk of ovarian cancer because her mother was diagnosed with breast cancer and testing for BRCA2 mutation should be recommended if not already completed. Increased risk of cervical cancer would include a positive HPV cytology. Women who have had breast cancer or ovarian cancer may have an increased risk of developing endometrial cancer, however this patient is only BRCA1 muta-tion positive and does not yet have the active dis-ease. )(Euhus, 2012, pp. 333-355)

A 24-year-old Hispanic woman, G3P2, presents for routine prenatal care at 20 weeks' gestation. Her urine is positive for glycosuria (2+). This finding would likely indicate (A) gestational diabetes. (B) need to follow-up with a 3-hour glucose tolerance test. (C) need for a 50-g, 1-hour glucose challenge test. (D) need for instituting dietary control. (E) normal increase in renal threshold for glucose.

C (Although glycosuria is more common during pregnancy because of the lowering of the renal threshold for glucose excretion, this patient may be at an increased risk for gestational diabetes (GDM) because of her ethnicity. Normal screening for GDM occurs at 24 weeks' gestation. Because gly-cosuria has been detected, screening with a 50-g, 1-hour glucose challenge test would be indicated at this time. Patients do not have to fast for this test. To be considered normal, serum or plasma glucose values should be less than 130 mg/dL (7.2 mmol/L) or less than 140 mg/dL (7.8 mmol/L). Using a value of 130 mg/dL or higher will increase the sensitivity of the test from 80% to 90% and decrease its spec-ificity, compared with using the 140 mg/dL cutoff. An abnormal 1-hour screening test should be fol-lowed by a 100-g, 3-hour venous serum or plasma glucose tolerance test. Normal blood sugars at 0, 1, 2, and 3 hours, respectively, are: • fasting blood sugar 95 mg/dL or less • 1-hour blood sugar 180 mg/dL or less • 2-hour blood sugar 155 mg/dL or less • 3-hour blood sugar 140 or less Adiagnosis of GDM is made if two or more sam-ples are increased or if any is greater than 200 mg/dL and the patient should be advised regarding die-tary control, regardless.) (Cunningham et al., 2014, pp. 1125-1146)

At an outpatient clinic, a 24-year-old female 16 weeks' gestation presents complaining of copious amounts of white vaginal discharge for the past 3 days. She is also complaining of vulvar irritation, dysuria, and pruritis. Wet mount reveals hyphae and budding yeast. Her BEST course of treatment would be (A) ciprofloxacin 250 mg orally, twice daily for 7 days.(B) clindamycin 300 mg orally, twice daily for 7 days.(C) clotrimazole 100 mg vaginal suppository, once daily for 7 days. (D) fluconazole 150 mg orally, one dose only. (E) metronidazole 500 mg orally, twice daily for 7 days.

C (Based on patient's history, physical, and wet mount, vaginal candidiasis is diagnosed and is very common during pregnancy due to hormonal changes, especially during the second trimester. Vaginal creams or suppositories are the recom-mended course of treatment since oral antifungals have not been proven safe during pregnancy or lac-tation. )(Workowski & Berman, 2010)

A 17-year-old complains of severe dysmenorrhea since her first menses at age 13. The dysmenorrhea is often accompanied by nausea and vomiting the first 2 days of her menstrual period; analgesics or heating pads do not relieve the pain. She is sexually active and does not want to get pregnant. Her pelvic examination is normal. Which of the following medications is MOST appropriate for this patient? (A) Luteal progesterone (B) Narcotic analgesics (C) Oral contraceptives (D) Oxytocin (E) Prostaglandin synthetase inhibitors

C (Conservative measures for treating dysmenor-rhea include heating pads, mild analgesics, and out-door exercise. Evidence suggests that primary dysmenorrhea is due to prosta glandin F2 alpha (PGF2 alpha), a potent myometrial stimulant and vasoconstrictor, in the secretory endometrium. Prostaglandin synthetase inhibitors such as naproxen, ibuprofen, indomethacin, and mefenamic acid can be very effective. However, for patients with dysmenorrhea who are sexually active, oral contraceptives will provide needed protection from unwanted pregnancy and generally alleviate the dysmenorrhea. The OCPs minimize endometrial prostaglandin production during the concurrent administration of estrogen and progestin.) (Hoffman, 2012, pp. 219-245)

A 26-year-old woman has undergone a suction curettage for a hydatidiform mole and was diag-nosed with benign gestational trophoblastic neopla-sia (GTN). Following this INITIAL treatment, which choice of monitoring should be done for patients in order to prevent the development of cho-riocarcinoma? (A) Administer prophylactic chemotherapy (B) Follow-up every 2 weeks with a urine pregnancy test (C) Monitor serum β-hCG once per week until three to four normal values are obtained, and then monthly for a year (D) Monitor serum hCG levels after 6 months and again at 1 year (E) Monitor serum hCG levels monthly accompanied by chest x-ray to rule out metastases

C (Gestational trophoblastic neoplasia (GTN) con-sists of benign GTN, most often a hydatidiform mole and malignant GTN, which includes nonmet-astatic and metastatic GTN. Approximately, 15% to 20% of women who have a complete hydatidiform mole and 2% to 4% of partial moles, will go on to develop some form of malignant GTN. Complete and partial molar pregnancies differ clinically, genetically, and histologically. Because of the risk for progression to malignancy, these patients must be monitored. After molar evacuation, serum radi-oimmunoassay β-hCG levels should be monitored weekly until they have become undetectable. Historically, monitoring has continued monthly after the undetectable levels for at least 6 additional months. However, studies have shown that it is safe to cease monitoring after a single blood sample demonstrates undetectable levels of β-hCG. Urine pregnancy tests are inadequate, and a sensitive radioimmunoassay is mandatory. Prophylactic chemotherapy is controversial because of signifi-cant drug toxicity and possible lack of efficacy; it is usually reserved for the highest risk cases or for patients who are unable to return for regular follow-up. Routine chest x-ray at every visit is not warranted unless hCG values rise.) (Schorge, 2012, pp. 898-917)

A 36-year-old female presents to family planning clinic at her local health department inquiring about birth control options. She is a ½ pack-day smoker and the only medication she is taking is lisinopril for her hypertension. Which of the following con-traceptives is MOST appropriate for this patient? (A) Combined oral contraceptive pills (B) Depot medroxyprogesterone acetate (C) Intrauterine device (D) Transdermal contraceptive patch (E) Vaginal ring (NuvaRing)

C (In patients over the age of 35, contraception options can be tricky. It is an absolute contraindica-tion to oral contraceptive use in women over the age of 35 and a smoker. The risk of stroke, pulmonary embolism, and hypertension outweighs the benefits. Even the vagina ring (NuvaRing) or the transdermal contraceptive patch causes an increased risk for vas-cular events. Depot medroxyprogesterone acetate should be used with caution secondary to the patient's history of hypertension and tobacco use. The most appropriate contraceptive option for this patient would be an intrauterine device (IUD). Either IUD, levonorgestrel IUD or the copper IUD, would be a suitable option for this patient and poses no increased risks. )(Frieden et al., 2010, pp. 1-86)

A 30-year-old G2P1 woman whose last menses was 8 weeks ago presents with heavy vaginal bleeding and left lower quadrant (LLQ) pain. She noted pas-sage of something that "looked like liver" the pre-vious day. Pelvic examination reveals a 2-cm cervical dilation. Which of the following is the MOST likely diagnosis?(A) Complete abortion (B) Incompetent cervix (C) Incomplete abortion (D) Missed abortion (E) Threatened abortion

C (In the classification of spontaneous abortions, an incomplete abortion is characterized by the pas-sage of tissue and an open cervical os. A complete abortion would have a similar history of passing tissue; however, pain or cramping would have sub-sided and the cervix would be closed. In a threatened abortion, there will be bleeding but no passage of tissue, and the cervical os would be closed. A missed abortion is defined by no symptoms and a closed os. With an incompetent cervix, women present with painless cervical dilation. The treatment of an incom-plete abortion is dilation and curettage. Serum-hCG levels are useful to follow after spontaneous abor-tion; hCG levels should halve every 48 to 72 hours, and a plateau could indicate residual retained tissue. )(Cunningham et al., 2014, pp. 350-376)

A 35-year-old female presents to an outpatient clinic for evaluation of amenorrhea. All of her laboratory work came back normal except for a positive preg-nancy test. Her last menstrual cycle was August 4, 2015. Her estimated date of delivery will be (A) April 26, 2016. (B) May 3, 2016. (C) May 10, 2016. (D) May 17, 2016. (E) June 3, 2016.

C (The estimated date of confinement (EDC) or due date is calculated after obtaining a thorough men-strual history. The date of the last onset of normal menses is key in determining EDC. If the patient is unaware of last menstrual cycle, an ultrasound should be performed for dating purposes. A "normal" preg-nancy lasts 40 ± 2 weeks. Calculated from the first day of the last normal menses, add 7 days to the first day of the last normal menstrual flow and subtract 3 months.) (Cunningham et al., 2014, pp. 167-193)

A 44-year-old female presents to an outpatient clinic with her 14-year-old daughter and is interested in the HPV vaccine. Which of the following should be discussed with the patient and her daughter? (A) The vaccine only protects against external genital warts (B) The vaccine only protects against cervical cancer (C) The vaccine must be given in three separate doses: 0, 2, and 6 months (D) The vaccine cannot be given until age 18 (E) Once the vaccine is given, Papanicolaou testing is not necessary

C (There are currently three vaccines approved by the Food and Drug Administration (FDA): quad-rivalent (Gardasil), 9-valent (Gardasil 9), and Bivalent (Cervarix). The vaccines target various subtypes of HPV which help to prevent against cervical cancer and precancer, vulvar and vaginal cancer, penile, anal, and oropharyngeal cancers as well as external genital warts. The vaccine is indicated in females and males aged 9 to 26. Although the vaccine helps to prevent against these types of cancers and warts, it is still vital to have routine Pap testing. The vaccine must be given in three separate intramuscular injection doses, 0, 2, and 6 months which is the correct response to this question. ) (Food and Drug Administration, 2014)

A 27-year-old G1P0woman has received regular prenatal care throughout her pregnancy. She pre-sents to the ED at 34 weeks with facial edema, severe headache, and epigastric pain. On physical examination, she has a blood pressure of 160/110 mm Hg, elevated liver function tests, and a platelet count of 60,000/uL. The baby is noted to be alive. Urinalysis indicates 4+ proteinuria. Which thera-peutic measure should be taken next in managing this patient? (A) Colloid solution for plasma volume expansion (B) Intravenous immunoglobulin therapy (C) Magnesium sulfate therapy and induction of labor (D) Oral antihypertensive therapy (E) Platelet transfusion

C (This patient has preeclampsia (BP ≥140/90 mm Hg, proteinuria, platelets <100,000, increased liver enzymes, headache, and epigastric pain). Because gestational hypertension also referred to commonly as pregnancy-induced hypertension has been associ-ated with raised rates of maternal morbidity and mor-tality and with many increased risks to the fetus, patients with moderate to severe preeclampsia should be delivered if the disease develops after 34 weeks' gestation. Magnesium sulfate is the treatment of choice for preeclampsia as it reduces the risk of eclampsia and probably maternal death. Hypertensive disease is classified into five types: gestational (also called pregnancy-induced), preeclampsia, eclampsia, preeclampsia superimposed on chronic hypertension, and chronic hypertension. Oral hypertensive drug therapy, though decreasing the risk of severe hyper-tension, has not been associated with decreased risk in the infant or mother. There is insufficient evidence for any effects of plasma volume expansion. Intra-vascular volume expansion carries a serious risk of volume overload, which could lead to pulmonary or cerebral edema. Patients with a platelet count greater than 40,000/mm3 are unlikely to bleed and do not require transfusion unless the platelet count drops to less than 20,000/mm3.) (Cunningham et al., 2014, pp. 455-472)

A 44-year-old G2P2woman who had two normal pregnancies (13 and 11 years ago) presents with the complaint of amenorrhea for 8 months. She has remarried and would like to become pregnant again. A pregnancy test is negative. Her physical exami-nation is normal. Which of the following tests is next indicated in the evaluation of this patient's amenorrhea? (A) Endometrial biopsy (B) Hysterosalpingogram (C) Luteinizing hormone, follicle- stimulating hormone, and estradiol levels (D) Ovarian antibody assay (E) Testosterone and dehydroepiandrosterone levels

C (This patient has secondary amenorrhea. The most common reason for amenorrhea in a woman of reproductive age is pregnancy, which has been ruled out. In the differential diagnosis for her secondary amenorrhea, possibilities include (among others) endometriosis, hypothyroidism, and prema-ture ovarian failure (if patient is aged less than 40), and ovarian failure or menopause if patient is older than 40. For a patient of this age, ovarian failure is more likely. Studies for establishing the diagnosis of ovarian failure are as follows: (1) serum FSH level, (2) serum LH, and (3) serum estradiol. Persistently elevated gonadotropin levels (espe-cially when accompanied by low serum estradiol levels) are diagnostic of ovarian failure. Ovarian antibody assay is a test with low sensitivity and specificity for determining the diagnosis of autoim-mune ovarian failure. Serum testosterone and DHEAS levels should be ordered only if the patient shows symptoms of androgen excess (acne, hir-sutism, male pattern balding, clitoromegaly) or hypertension. The hysterosalpingogram is part of an infertility work-up that may demonstrate Asherman syndrome, but is more invasive and not indicated until ovarian failure has been excluded.)(Halvorson, 2012a, pp. 440-459)

A 62-year-old female presents to clinic complaining about a bulge from her vagina. She states that the area has grown in size over the past 6 months and has had worsening pelvic pressure after a vaginal hysterectomy over 1 year ago. Patient does com-plain of vaginal dryness and the feeling that she does not empty her bladder to completion with each void. On physical examination, there is a bulge from the upper one-third of the vagina and 1-cm protrusion from the vaginal introitus with valsalva as well as weak pelvic floor muscles and vaginal atrophy. What is her BEST course of treatment? (A) Oral anticholinergics (B) Oral estrogen therapy (C) Pessary insertion (D) Surgical intervention (E) Vaginal estrogen therapy

C (This patient would be diagnosed with a cysto-cele or anterior vaginal wall prolapse. A cystocele may result from muscle straining during vaginal delivery or with heavy lifting and is often seen after pelvic surgeries, such as a vaginal hysterectomy. Cystoceles are graded—grade 1 when the bladder droops only a short way into the vagina, grade 2 when the bladder sinks far enough to reach the opening of the vagina and the most advanced, grade 3 when the bladder bulges out through the opening of the vagina. This patient would be diagnosed with a grade 2 cystocele because during rest, the cysto-cele does not protrude past the vaginal introitus. Large cystoceles may require surgery especially if there is urinary retention, however for this patient a pessary would be the best initial therapy. Adjunct therapy should also include vaginal estrogen ther-apy to avoid ulceration of the vaginal wall from the pessary. )(Lentz, 2012, pp. 453-474)

A 26-year-old mother who is nursing presents to clinic complaining of right breast tenderness and fever. Upon physical examination, she has a 2-cm fluctuant mass at the site of erythema and tender-ness. The patient had been seen 4 days ago and was placed on oxacillin, which she has been taking. At this point, the BEST treatment is (A) changing antibiotic to vancomycin and discontinuing nursing. (B) discontinuation of nursing and hot soaks. (C) hot packs and manual emptying of breasts. (D) incision and drainage, hot soaks, antibiotics, and breast emptying. (E) surgical drainage and continuation of nursing.

D (A true abscess will require surgical drainage and therapy with antibiotics, rest, warm soaks, and complete emptying of the breasts every 2 hours. The abscess drainage should be cultured and sen-sitivities determined. There have been no formal studies of treatment of lactation mastitis associated abscesses. However, incision and draining is rec-ommended along with parenteral antibiotics administered with added coverage for anaerobic bacteria. As soon as the pain of the wound permits, breastfeeding or pumping should be resumed in order to drain the affected breast.) (Euhus, 2012, pp. 333-355)

Which of the following is the most significant risk factor for the development of abruption placentae? (A) Abdominal trauma (B) Advanced maternal age (C) Gestational diabetes (D) Maternal hypertension (E) Previous miscarriage

D (Abruptio placentae or premature separation of the normally implanted placenta, complicates 0.5% to 1.5% of all pregnancies. The most common risk factor associated with abruptio placentae is mater-nal hypertension, either chronic or as a result of preeclampsia. Other risk factors include prior pla-cental abruption, trauma, polyhydramnios with rapid decompression, premature rupture of mem-branes, short umbilical cord, tobacco use, and folate deficiency. The diagnosis of an abruptio placentae is based on painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone.) (Kim et al., 2010, pp. 130-131)

A previously desensitized Rh-negative woman in her second pregnancy is seen in her 26th week. She complains of edema in her legs and some tingling in her left hand. What is the next step in managing this patient? (A) Amniocentesis (B) Analysis of the husband's blood type (C) Intramuscular Rho (anti-D) immune globulin (D) Rh antibody titer (E) Ultrasonic evaluation of amniotic fluid volume

D (An Rh-negative woman must be tested for the presence of antibodies at the beginning of the third trimester (usually at 28 weeks) so that the rare Rh sensitization of that pregnancy can be detected. If she is negative she is given Rho (anti-D) immune globulin. If she is positive for Rh sensitization, she may require intrauterine blood transfusion to prevent erythroblas-tosis fetalis. In mothers who receive Rh immunoglob-ulin, the risk of isoimmunization is reduced from 16% to 0.2%. )(Roman, 2013, pp. 250-266)

A 14-year-old female presents to the emergency department complaining of fullness in her lower abdomen, lower back pain, urinary urgency, and constipation. Patient is not sexually active and denies menarche. Urinalysis and complete blood count (CBC) are within normal limits. On physical examination, she has suprapubic discomfort to pal-pation and pelvic examination shows a thin, bulg-ing, dark bluish membrane covering her vaginal introitus. What would be the BEST initial interven-tion for this patient? (A) Biopsy (B) Incision and drainage (I&D) (C) General surgical consult (D) Gynecology consult (E) Papanicolaou test

D (Based on patient's history and physical exami-nation, an imperforate hymen should be her diagno-sis. If not detected until after menarche, an imperforate hymen may be seen as a thin, dark bluish or thicker clear membrane blocking men-strual flow at the introitus. There are no imaging studies that would help to validate the diagnosis and a gynecology consult should be implemented for immediate surgery with an elliptical excision of the membrane followed by evacuation of the obstructed material. A general surgery consult would not be the most appropriate referral since this type of proce-dure is generally not performed by a general sur-geon. )(Domany et al., 2013)

When counseling a 53-year-old postmenopausal female regarding the risks and benefits of a short course (<5 years) of hormone replacement therapy (HRT), which of the following is a documented risk of HRT that should be discussed? (A) Increased risk of endometrial cancer (B) Increased risk of breast cancer (C) Decreased bone mineral density (D) Increased risk of thromboembolism (E) Increased risk of colon cancer

D (Currently, hormone replacement therapy (HRT) is indicated only for the treatment of vasomotor symptoms of menopause, vaginal atrophy, and for the treatment and prevention of osteoporosis. HRT increases an older woman's risk of CHD, and in all women it increases their risk of breast cancer, stroke, and thromboembolism. Increased risks of breast cancer are seen in women who use HRT for longer than 5 years. Estrogen-only therapy given to women with an intact uterus increases the risk of endometrial hyperplasia (thickening of the lining of the uterus) and eventually endometrial cancer. Daily estrogen combined with progesterone given for 10 to 14 days per month (sequential HRT) reduces this risk but does not eliminate it.) (Euhus, 2012, pp. 333-355)

A man and woman in their 20s have been trying unsuccessfully to conceive for the last year. The woman has regular menses and a 28-day cycle. In the initial evaluation, which of the following tests or evaluations should be considered first line? (A) Endometrial biopsy (B) Hysterosalpingogram (C) Postcoital testing (D) Semen analysis (E) Transvaginal ultrasound

D (Generally, infertility is defined as the inability for a couple to conceive after reasonably frequent unprotected intercourse for 1 year.In approaching the diagnostic work-up for infertility, with a thor-ough physical examination and history of both part-ners, the clinician should establish the following points: (1) does the woman ovulate? (if not, why not); (2) does the semen have normal characteris-tics? (3) is there a female reproductive tract abnor-mality? Noninvasive tests should be done first line. For the male partner, semen analysis is noninvasive and helpful, though not diagnostic. In the initial evaluation of the female partner, noninvasive proce-dures, such as the measurement of LH and midlu-teal phase progesterone (to determine ovulatory function) and transvaginal ultrasound (to rule out the possibility of fibroids or polycystic ovaries), are first-line investigations. Pelvic ultrasound should also be part of the routine gynecologic evaluation because it allows a more precise evaluation of the position of the uterus within the pelvis and provides more information about its size and irregularities. Hysterosalpingography is an invasive procedure and therefore not first line in the evaluation. Endometrial biopsy and postcoital testing are no longer recommended for the routine infertility eval-uation because they have poor predictive value.) (Halvorson, 2012b, pp. 400-439)

A 30-year-old woman who is nursing presents to the clinic complaining of breast tenderness. Physical examination reveals a warm, erythematous, tender area with induration of the right breast. The next step in management would be to (A) culture breast drainage to determine causative organism. (B) discontinue nursing, empty breasts, and apply hot soaks to affected breast. (C) observe for fever and rest while continuing breastfeeding without medication. (D) prescribe dicloxacillin (Dynapen). (E) prescribe topical mupirocin and continue breastfeeding.

D (Mastitis is an inflammation of the breast that is common in breastfeeding women. In order to make a diagnosis of mastitis, there must be an area of hardness, pain, redness, and swelling in the breast. It can be caused by engorgement, a blocked milk duct, or a cracked nipple that allows bacteria to enter. The most common pathogen in infective mas-titis is penicillin-resistant S. aureus. Less common pathogens are Streptococcus or E. coli. The pre-ferred antibiotics are usually penicillinase-resistant penicillins such as dicloxacillin, with patients usu-ally responding within 24 to 26 hours. In addition to antibiotic treatment, regular emptying of the breast by breastfeeding and/or pumping is neces-sary to prevent more bacteria from collecting in the breast. There is no evidence of risk to the healthy, term infant from continuing breastfeeding. Symptomatic treatment such as application of heat (e.g., a shower or a hot pack) to the breast prior to feeding may help with the milk flow. )(Cunningham et al., 2014, pp. 668-681)

Which of the following elements of a patient's history is the greatest risk factor for endometrial cancer? (A) Age greater than 70 years (B) Combination progestin and estrogen hormone therapy (C) Obesity (D) Postmenopausal bleeding (E) Tobacco use

D (More than 90% of patients with endometrial cancer present with postmenopausal bleeding, thus making it the hallmark history component. In the United States, endometrial cancer is the most common gynecologic cancer. There are approxi-mately 39,000 cases of endometrial cancer diag-nosed each year and about 7,400 patients die from the disease. Of all endometrial cancer cases, 75% are type I and 25% are type II. There are several risk factors for developing type I endometrial cancer, but in general excessive estrogen is the cause. Therefore, women who are taking postmenopausal unopposed estrogen replacement or tamoxifen and women who are 50 lb above their ideal body weight are at risk for endometrial hyperplasia and endome-trial cancer. Type II endometrial cancers tend to occur in older, thinner women without exogenous estrogen exposure.) (Miller, 2012, pp. 817-838)

At 33 weeks' gestation, a 28-year-old patient, G1P0, calls the office with a complaint of a fluid gush from her vagina. She is not having contrac-tions or evidence of bleeding. She is advised to go to labor and delivery to be examined. Which of the following procedures should be performed first? (A) Administration of antibiotics to prevent infection (B) Digital cervical examination to determine whether patient is in labor (C) Induction of labor (D) Sterile speculum examination or nitrazine testing (E) Ultrasound to estimate amniotic fluid volume

D (The accurate diagnosis of spontaneous rupture of membranes is important in order to ascertain whether he patient has begun labor or if the patient has pre-mature rupture of membranes (this patient is 33 weeks). To evaluate for spontaneous rupture of mem-branes, a sterile speculum examination is performed with the patient in the dorsal lithotomy position. Evidence of rupture of membranes would be clear when blood-tinged fluid in the posterior fornix of the vagina, or pooling, and escape of clear fluid from the cervical os occurs when the patient coughs. Nitrazine testing can distinguish amniotic fluid from urine or vaginal secretion samples from speculum examina-tion. If the pH is 7.1 to 7.3, it will show positive on nitrazine paper (dark blue). False positives can occur, however, with cervical mucus, blood, or semen in the sample. Until rupture of membranes has been ascer-tained, this patient should not be induced because of risk of prematurity in the fetus. Ultrasound determi-nation of amniotic fluid volume is an important means of evaluating premature and preterm rupture of membranes, but it is not a means of diagnosing rupture of membranes. Digital cervical examination should not be performed because this would increase the risk of ascending infection.) (Cunningham et al., 2014, pp. 433-454)

During a routine well woman examination on a 34-year-old female patient, cervical cysts are noted while performing a Papanicolaou test. The MOST likely treatment is (A) loop electrosurgical excision procedure (LEEP). (B) metronidazole (Flagyl) 500 mg orally, twice daily for 14 days. (C) miconazole vaginal suppository twice daily for 3 days. (D) no treatment is needed.(E) trichloroacetic acid topical weekly until gone.

D (The cervical cysts seen during the Pap test are Nabothian cysts which are a very common benign finding. They result from the process of squamous metaplasia where a layer of superficial squamous epithelium entraps an invagination of columnar cells beneath the surface. The underlying columnar cells continue to secrete mucus and a mucous reten-tion cyst is created. Nabothian cysts are opaque with a yellowish or bluish hue, varying in size from 0.3 to 3 cm.) (Nelson & Gambone, 2010, p. 246)

A 20-year-old sexually active woman complains of a profuse, whitish gray vaginal discharge with a fishy odor that becomes stronger after intercourse and during menses. She denies any irritation and states that her sexual partner has no symptoms. Microscopic evaluation of the discharge reveals granular-appearing epithelial cells. Which of the following is the BEST therapy? (A) Ciprofloxacin (Cipro) (B) Doxycycline (C) Fluconazole (Diflucan) (D) Metronidazole (Flagyl) (E) Miconazole cream (Monistat)

D (The most likely diagnosis of this vaginitis is bacterial vaginosis (BV) and the treatment is met-ronidazole 500 mg twice daily for 7 days. Other treatments include vaginal preparations of metroni-dazole and also vaginal preparations of clindamy-cin. The other treatments would be inappropriate for the treatment of BV. Ciprofloxacin is a treatment for a urinary tract infection. Miconazole cream and flu-conazole are treatments for yeast vaginitis. Doxycycline is the treatment for chlamydia tra-chomatis. )(MacKay, 2014, pp. 701-731)

A 46-year-old perimenopausal woman presents to an outpatient clinic complaining of hot flashes affecting her quality of life. Her menstrual cycles have been irregular for the past year and is currently on no medications. Patient retains all of her female reproductive organs. She has tried lifestyle modifi-cation however nothing has improved her symp-toms and is interested in hormonal replacement therapy. What would be her BEST treatment option? (A) Alpha agonists (B) Oral estrogen only (C) Oral progesterone only (D) Oral combination estrogen/progesterone (E) Serotonin selective reuptake inhibitors (SSRI's)

D (The patient is experiencing vasomotor symp-toms associated with menopause. Hot flashes are the second most frequently reported perimenopau-sal symptom, after irregular menses, and are con-sidered the hallmarks of perimenopause. Nearly 25% of women experience severe discomfort from vasomotor symptoms and seek help from a health-care provider. Lifestyle modifications should be initiated first, however, this patient has failed life-style changes and would benefit from hormonal replacement therapy. A combination estrogen and progesterone regimen would be appropriate treat-ment option for this patient. Since the patient retains her uterus, progesterone needs to be added with the estrogen as this reduces the risk of endometrial ade-nocarcinoma compared to unopposed estrogen. Use of this therapy should be limited to the shortest duration consistent with treatment goals, benefits, and risks for the individual woman. Initiating com-bination therapy during the perimenopausal period is associated with lower risk than starting therapy several years after menopause.) (Bradshaw, 2012, pp. 554-580)

A 37-year-old female in her third week postpartum presents complaining of recent onset of breast pain with firmness to her right upper outer quadrant. She is lactating however has noticed decreased milk pro-duction despite continuing breastfeeding. Upon examination, her breast is firm, warm, edematous, and erythematous. Which of the following is the most common pathogen causing this patient's diagnosis? (A) Enterococcus faecalis (B) Escherichia coli (C) Group B Streptococcus (D) Staphylococcus aureus (E) Streptococcus pyogenes

D (The patient is suffering from mastitis. In most cases, lactation mastitis occurs within the first 4 weeks. First symptoms are usually slight fever and chills followed by redness of a segment of the breast which becomes indurated and painful. The etiologic agent is usually S. aureus, which originates from the infant's oral pharynx. Milk should be obtained from breast for culture and sensitivity. The mother should be immediately placed on penicillinase-resistant antibiotic, such as dicloxacillin. Breastfeeding may be discontinued but is not contraindicated.) (Hobel & Zakowski, 2010, p. 110)

A 58-year-old woman who is 8 years postmenopau-sal complains of urinary urgency, frequency, and occasional incontinence. On pelvic examination, her vaginal mucosa appears shiny, pale pink with white patches, and bleeds slightly to touch. Her uri-nalysis and urine cultures are negative. Which of the following is the BEST treatment for this patient? (A) Oral antibiotics (B) Surgical procedure (C) Topical testosterone cream to affected areas (D) Topical vaginal estrogens (E) Vaginal suppositories containing sulfa antibiotics

D (The patient's symptoms describe postmenopau-sal atrophic changes affecting the vagina, bladder, and urethra. In women with more severe changes, vaginal irritation, dyspareunia, and fragility may become problems. Atrophy is diagnosed by the presence of a thin, clear, or bloody discharge; a vag-inal pH of 5 to 7; loss of vaginal rugae; and the finding of parabasal epithelial cells on microscopic examination of a wet-mount preparation. These symptoms are all due to estrogen depletion. Treatment with topical estrogen preparations (cream, tablet, or ring) appears equally effective. Complete relief of symptoms usually occurs within weeks; in the interim, patients may obtain relief through use of vaginal lubricants and moisturizers (e.g., Astroglide, Replens). Rarely, endometrial hyperplasia can be a side effect of vaginal estrogen treatment.) (Nathan, 2013, pp. 953-956)

A 23-year-old female presents to the outpatient clinic with irregular menses and abnormal men-strual bleeding. Based on the most likely diagnosis of dysfunctional uterine bleeding in this patient's age group, which of the following symptoms would likely be elicited during the history? (A) Deep thrust dyspareunia, pelvic pain, and headache (B) Dysmenorrhea, headache, insomnia, and pelvic pain (C) Dysuria, introital dyspareunia, insomnia, pelvic pain (D) Dysmenorrhea, deep thrust dyspareunia, and pelvic pain (E) Dysmenorrhea, introital dyspareunia, constipation, and dysuria

D (There is great variability in the symptoms with which endometriosis will present. Some women may even be asymptomatic, but endometrial lesions may be found during laparoscopy for other gynecologic reasons. The classic symptoms of endometriosis are dysmenorrhea, deep thrust dyspareunia, infertility, abnormal bleeding, and pelvic pain. Thorough his-tory taking greatly helps in the diagnosis, but the definitive diagnosis is made when the lesions are vis-ualized during laparoscopic surgery or by tissue biopsy. )(Beckman et al., 2014, pp. 295-300)

A 20-year-old female college student presents com-plaining of recent onset vaginal pruritis, discharge, and odor. On physical examination, a thin yellow discharge is observed along with "strawberry spots" on the cervix. The wet prep reveals a pH of 6.0, positive whiff test, and mobile protozoan. What is the best treatment for this patient? (A) Acyclovir 400 mg by mouth, 3 times daily, for 7 days (B) Fluconazole 150 mg by mouth, one dose (C) Metronidazole 500 mg by mouth, twice daily, for 7 days (D) Metronidazole 2 g by mouth, one dose (E) Miconazole 2% cream, 5 g intravaginally, for 7 days

D (This patient would be diagnosed with trichomo-niasis based on her symptoms and positive wet mount with protozoans. Women with trichomonia-sis may notice pruritis, burning, genital erythema, dysuria, yellow-greenish frothy vaginal discharge. Upon speculum examination a strawberry cervix with vaginal discharge can also be appreciated. The CDC recommends treatment with metronidazole 2 g orally as a single dose. Alcohol consumption should be avoided during treatment and for 24 thereafter. Sexual partners should also be treated and offered screening for other sexually transmitted infections. The metronidazole 500 mg dose listed is for the treatment of bacterial vaginosis. The flu-conazole and miconazole are for the treatment of vaginal candidiasis. The acyclovir is for the treat-ment of an initial herpes outbreak.) (Hemsell, 2012, pp. 64-109)

A 28-year-old primigravida woman at 42 weeks' gestation delivers a 4,000-g (8 lb 13 oz) newborn. Labor stages are as follows: first stage, 17 hours; second stage, 4 hours; third stage, 35 minutes. After an episiotomy was performed, the baby was deliv-ered with low forceps. The placenta appeared to be intact. Ten minutes after delivery, she experiences vaginal bleeding estimated to be 500 mL over a 5-minute period. Upon examination, her uterus feels soft and boggy. Which of the following is the MOST likely cause of the hemorrhage? (A) Disseminated intravascular coagulation (B) Genital tract laceration (C) Retained placental tissue (D) Uterine atony (E) Uterine inversion

D (Uterine atony is responsible for ~50% of post-partum hemorrhage (PPH). Several factors may predispose to uterine atony including conditions that enlarge the uterus (e.g., multiple gestations, multiparity, microsomy, hydramnios), abnormal labor (e.g., precipitous or prolonged delivery, general anesthesia, prolonged labor, use of forceps), and conditions that interfere with uterine contrac-tion (e.g., uterine leiomyomas, magnesium sulfate use). Vaginal and cervical lacerations are less common than uterine atony, but are serious and require prompt surgical attention. Retained pla-centa, secondary to lack of complete separation from the uterus and abnormally adherent placenta, such as placenta accreta, are less common causes of PPH. Although coagulation studies should be part of the work-up, in the immediate postpartum period, disorders of the coagulation system and platelets do not usually result in excessive bleeding. Fibrin dep-osition over the placental site and clots within sup-plying vessels play a significant role in the hours and days following delivery, and abnormalities in these areas can lead to late PPH or exacerbate bleeding from other causes, most notably, trauma. Uterine inversion is a rare condition.) (Poggi, 2013, pp. 349-368)

A 36-year-old female presents to an outpatient clinic complaining of burning pain on her left labia radiating to her inner thigh. Patient states that the pain is worsened with tight fitting clothes and pro-longed sitting. She states that her primary care pro-vider could not find anything abnormal on physical examination and her urinalysis was negative. Labs performed today are negative for candida, sexually transmitted infections, and vaginal atrophy. She does tell you that 6 months ago she had a motorcy-cle accident and bruised her pelvis. What is the next best step to confirm the most likely diagnosis? (A) CT scan (B) CT scan of pelvis (C) MRI of pelvis (D) Q-tip test (E) Wet mount

D (Vulvodynia is chronic vulvar pain without an identifiable cause. The location, constancy and sever-ity of the pain vary among sufferers. The most common symptom reported is burning. Vulvodynia is broken down into two main subtypes: localized and generalized. After taking a thorough medical his-tory a careful examination of the vulvar should be performed along with a Q-tip test with a cotton-swab, according the National Vulvodynia Association. A vulvar biopsy is not necessary on a routine basis, but is helpful to diagnose suspected skin disorders. It is also important to rule out other possible causes such as infections, skin disease, trauma, systemic disease, skin precancer and cancer, and irritants. The Q-tip test is a simple diagnostic test—imagine the vestibule as the face of a clock with 12 just above the urethra and the 6 at the bottom. Touching around the vesti-bule "clock" with a cotton swab produces pain in one or more places with the 6 o'clock position eliciting the most pain. )(Haefner, 2013)

A 28-year-old patient presents for annual well woman physical. She is concerned about a 1-cm right breast mass she found on a self-breast examination last month. During the clinical breast examination, the mass is easily mobile, firm, painless upon palpa-tion, and rubbery in consistency. What diagnostic study should be considered first in this patient? (A) Fine-needle aspiration biopsy (B) Magnetic resonance imaging (C) Mammogram (D) Open breast biopsy (E) Ultrasound

E (A fibroadenoma is the most common benign tumor found in the female breast. Clinically, these tumors are sharply circumscribed, freely mobile, may occur at any age, but are more common in women younger than 30 years of age. An ultrasound should be performed first to determine consistency of the tumor and may be followed with a mammogram if the ultrasound is inconclusive. A biopsy may be done to get a definite diagnosis, especially for women over the age of 30. Women with fibroadenomas have a slightly higher risk of breast cancer and follow up with watchful waiting and monthly self-breast exam-inations is recommended. If there are changes to the tumor, a biopsy or surgical removal may be war-ranted. )(Katz & Dotters, 2012, pp. 301-334)

A 26-year-old female at 34 weeks' gestation pre-sents concerned about lack of fetal movement. An ultrasound and stress test is ordered. Which of the following nonstress tests results is most reassuring? (A) No change in the fetal heart rate with fetal movements over a 30-minute period (B) Two decelerations with fetal movements over a 40-minute period (C) One acceleration with fetal movements over a 1-hour period (D) Five decelerations with fetal movements over a 20-minute period (E) Two accelerations with fetal movements over a 20-minute period

E (A reactive stress test (normal) is defined as two or more fetal heart rate increases in 20 minutes. The accelerations increase by 15 beats for 15 seconds and are related to fetal movement. A nonreactive stress test (abnormal) requires monitoring for two 20-minute periods where neither period yields ade-quate accelerations.) (Cunningham et al., 2014, pp. 433-454)

A 45-year-old female, G4P4, presents concerned about increased pelvic pressure and a large bulge protruding from her vaginal introitus. Examination reveals a large uterine prolapse. Surgical repair of her prolapse will most likely involve repairing which of the following structures? (A) Detrusor muscles (B) Levator ani muscle (C) Obturator internus muscle (D) Sacral nerve (E) Transverse and uterosacral ligaments

E (Childbirth can injure the pelvic floor muscles resulting in a prolapsed uterus. The transverse and uterosacral ligaments are particularly affected. The degree of protrusion of the uterus in relationship to the introitus determines the classification. Grade 0 is normal position of the uterus. Grade 1 or slight prolapse is when the uterus descends toward the introitus, but is still in the vagina. Grade 2 or mod-erate prolapse is when the uterus and cervix descend to the introitus, and grade 3 or marked prolapse is when the cervix and uterus descend past the hymen halfway. Grade 4 is when the uterus is at the maxi-mum descent. When the prolapse interferes with daily life or quality of life, a surgical repair is indi-cated.) (Schaffer, 2012, pp. 633-658)

A 17-year-old female patient presents to an outpa-tient clinic and is requesting emergency contracep-tion after having unprotected intercourse 4 days ago. Should this patient receive emergency contra-ception based on her time frame for the greatest effectiveness in preventing a pregnancy? (A) No, time frame should be 0 to 24 hours (B) No, time frame should be 24 to 48 hours (C) No, time frame should be 48 to 72 hours (D) No, time frame should be 72 to 96 hours (E) Yes, time frame should be less than 120 hours

E (Emergency contraception (EC) can stop a preg-nancy before it starts. There are four types of EC and they all work up to 5 days or 120 hours after unprotected intercourse, however, effectiveness can decrease each day and should be used sooner rather than later. Types of EC include Paragard IUD, ulipristal (Ella), levonorgestrel-based pills (Plan B One-Step, Next Choice One Dose, Next Choice, My Way), and Yuzpe Regimen (using certain birth con-trol pills as EC).) (Hatcher et al., 2011, pp. 277-290)

A 35-year-old primipara at 39 weeks' gestation is in the labor and delivery suite for a nonstress test. She has had an uneventful pregnancy but has not felt the fetus moving much in the past 24 hours. A subsequent external fetal monitor tracing demonstrates a repetitive late heart rate deceleration. The first step in managing this patient is (A) administration of a tocolytic agent. (B) checking maternal oxygen saturation. (C) evaluation of maternal hypotension. (D) evaluation of fetal acid-base status. (E) repositioning the patient

E (Fetal heart rates by fetal monitoring are described by rate and pattern of variability. Baseline is defined as 120 to 160 bpm. Late decelerations are a symmet-rical fall in fetal heart rate (FHR) beginning at or after the peak of the uterine contraction and return-ing to baseline only after the contraction has ended. They indicate possible uteroplacental insufficiency and imply some degree of fetal hypoxia. Remedial techniques are empirically designed to overcome uteroplacental insufficiency or to decrease cord compromise and improve placental and fetal oxy-genation. Changing maternal position to right/left side lying recumbent or knee-chest position is a rea-sonable and quick first step. Late FHR decelerations, however, are an ominous sign and should be evalu-ated quickly and seriously. Persistent nonreassuring tracings indicate the need for emergent delivery. Other remedial techniques include the following: IV infusion, mask oxygen, stopping oxytocics, subcu-taneous terbutaline, and amnioinfusion.)(Cunningham et al., 2014, pp. 433-454)

A 39-year-old woman, G3P3, complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Endometrial biopsy findings are normal. Which diagnostic examination is needed next?(A) Computed tomography (CT) scan of the pelvis (B) Hysterosalpingography (C) Laparoscopy (D) Magnetic resonance imaging (MRI) (E) Transvaginal and abdominal ultrasound

E (It is important to evaluate why this patient has an enlarged and tender uterus; therefore, the next step in evaluation would be ultrasound. Common causes of secondary dysmenorrhea in this age group are endometriosis, adenomyosis, and the presence of an intrauterine device. For this patient, it would be important also to rule out leiomyomas, endometrial polyps, and tumors. Given the most common causes, endometriosis and adenomyosis, noninvasive studies with transvaginal and abdom-inal ultrasound would be a reasonable (and eco-nomical) first choice. The imaging diagnosis of adenomyosis is usually made by using TVUS or, more expensively, by MRI. Abdo minal ultrasound alone can be highly sensitive for detecting masses, but often lacks specificity for the diagnosis of ade-nomyosis or endometrio sis. Hysterosalpingography is more invasive and is used to exclude endome-trial polyps, leiomyomas, and congenital abnor-malities of the uterus. The inability to resolve subtle differences in soft tissue attenuation limits the usefulness of computed tomography (CT). Laparoscopy is often needed as a last resort to make the diagnosis of endometriosis where surgi-cal correction can occur simultaneously.) (Hoffman, 2012, pp. 219-245)

A 32-year-old, G2P0 presents to an outpatient clinic at 34 weeks' gestation. Her prenatal care has been routine for twin gestations without any complica-tions. Today, she is complaining of low pelvic "cramping." While at the office she has had four cramping episodes in the last 20 minutes and upon pelvic examination is at least 2 cm dilated. What is of greatest concern for this patient at this time? (A) Incompetent cervix (B) Intrauterine fetal demise (C) Gestational diabetes (D) Preeclampsia (E) Preterm labor

E (Multiple gestations are at a higher risk for pre-term labor and this patient is already eliciting signs and symptoms of preterm labor. The American College of Obstetricians and Gynecologists defines preterm labor as regular contractions associated with cervical change before 37 weeks' gestation. The following are criteria to diagnose preterm labor: (1) four contractions in 20 minutes or 8 con-tractions in 60 minutes; (2) cervical dilation greater than 1 cm; (3) cervical effacement of greater than 80%. Multiple gestations include various complica-tions for the mother and fetus. For the mother, twin pregnancies are associated with higher risk of preg-nancy-induced hypertension, anemia, hyperemesis, abruption, placenta previa, postpartum hemorrhage, and increased risk of operative delivery. For the fetus, twin pregnancy increases risk of intrauterine death, spontaneous abortion, congenital anomalies, cerebral palsy, and intrauterine growth retardation. Twin pregnancies have a similar risk of gestational diabetes compared to singleton pregnancies, and so this is not a risk for this patient at all. )(Cunningham et al., 2014, pp. 473-503)

A 36-year-old G2P2 complains of heavy menstrual bleeding for the past year. The patient is bleeding through a super tampon and a heavy pad every hour of the first 3 days of her cycle. Her cycle lasts 5 days and the cycle length has decreased to having a period every 20 days. She complains of fatigue. Her physical examination and laboratory work-up are normal (negative β-hCG, luteinizing hormone [LH], follicle stimulating hormone [FSH], prolactin, clotting times, liver function, and renal function tests), except for the complete blood cell count (CBC) and further labs indicating she has iron deficiency anemia. The patient's weight is 298 lb. In addition to iron supplementation, which of the following is the BEST INITIAL therapy for this patient? (A) Daily dosing of aspirin (B) Dilation & curettage of the endometrium (C) Hysterectomy (D) Long-term conjugated estrogen therapy (E) Oral contraceptives

E (Oral contraceptives are the best treatment for this patient. Treatment for premenopausal abnormal uterine bleeding is varied. Once infection, fibroid tumors, pregnancy, neoplasm, and iatrogenic causes (e.g., medication related) are ruled out, a woman may be treated hormonally to control bleeding. In this patient, the most likely cause of the bleeding is anovulatory cycles caused by estrogen excess due to her obesity; in addition, the iron deficiency anemia also can cause menometrorrhagia. In patients with irregular cycles, secondary to chronic anovulation, or oligoovulation, combined oral con-traceptive (COC) pills help to prevent the risks associated with prolonged unopposed estrogen stimulation of the endometrium. Treatment with cyclic progestins for days 16 through 25 following the first day of the most recent menstrual flow is preferred when OCP use is contraindicated, such as in smokers older than age 35 and women at risk for thromboembolism.) (Hoffman, 2012, pp. 219-245)

A 37-year-old G2P2 woman presents to your office complaining of low libido for the past year. She is currently in a monogamous relationship with her husband and denies any vaginal dryness, dyspareunia, or anorgasmia. Current medications include meto-prolol (Lopressor), sertraline (Zoloft), omeprazole (Prilosec), cetirizine (Zyrtec OTC) and multivita-min. Which of her medications is most likely con-tributing to the patient's symptoms? (A) Cetirizine (B) Metoprolol (C) Multivitamin (D) Omeprazole (E) Sertraline

E (The medication most responsible for the patient's low libido is sertraline secondary to its increased serotonin levels, which create negative effects on the limbic system in the brain, therefore lowering a patient's sexual desire. Metoprolol also has negative effects on sexual functioning however beta blockers decrease the compliancy of blood ves-sels affecting blood flow causing decreased arousal, not decreased libido.) (Clayton et al., 2014)

At her annual examination, a 36-year-old woman is concerned about worsening abdominal bloating, urinary urgency and anorexia over the past 6 months. Upon pelvic examination, a very firm, right ovarian mass is palpated. Which of the following interventions should be considered first with this patient? (A) Chemotherapy (B) Exploratory laparoscopy (C) Oral contraceptives (D) Radiation therapy (E) Surgical oncologist consult

E (The size and firmness of the ovarian mass sug-gests endometrioid carcinoma, a tumor in which the potential for malignancy is 100%. Referral to a gynecologic oncologist should be considered first whenever an ovarian malignancy is suspected. Standard of care is complete surgical staging, exci-sion of all visible masses, and abdominal hysterec-tomy and bilateral salpingo-oophorectomy followed by chemotherapy. Radiation oncology could also be considered.) (MacKay & Woo, 2014, pp. 726-758)

Which of the following risk factors places a woman at the highest risk of developing an ectopic preg-nancy? (A) Advanced maternal age (B) Amenorrhea (C) History of spontaneous abortion (D) History of oral contraceptive use (E) History of pelvic inflammatory disease

E (Women with a prior history of PID are at 7 to 10 times increased risk in having an ectopic preg-nancy. In decreasing order, the next most common risk factors include tubal surgery, intrauterine con-traceptive devices, previous ectopic pregnancy, in vitro fertilization, smoking, previous abdominal surgery, and induced abortions.) (Gala, 2012, pp. 198-218)