CC OB and Peds

Question 1

In the US, the leading cause of maternal death associated with a live birth is:

A. Pregnancy induced HTN
B. PE
C. Cardiomegaly
D. Hemorrhage

Answer 1

Answer: B: PE at 21%, second is PIH

Question 2

On a per kg basis, ventilatory parameters that remain unchanged from birth throughout adulthood include:

A. Deadspace
B. MV
C. FRC
D. CC

Answer 2

Answer: D

Also, Tidal volume

Question 3

Well oxygenated fetal blood from the placenta has a PaO2 of approximately:

A. 40 mmHg
B. 60 mmHg
C. 80 mmHg
D. 100 mmHg

Answer 3

Answer: A

Question 4

After delivery of a 4.0kg neonate, recurrent bradycardia is noted. An umbilical artery catheter is placed at which time the neonate becomes systolic. An appropriate dose of ephedrine would be:

A. 0.01 mg
B. 0.25 mg
C. 0.04 mg
D. 0.50 mg

Answer 4

Answer: C

Epinephrine 0.01 - 0.03
mg/kg is indicated for
neonatal bradycardia (< 60
bpm) and asystole. This is
usually delivered as a
1:10,000 solution.

Question 5

A preterm (33 week gestation) neonate is delivered emergently by a C/S. The baby shows tachypnea, grunting, intercostal retractions and is cyanotic. The most likely cause of the cyanosis is

A. Insufficient surfactant production
B. Transposition of the great vessels
C. Insufficient HbgF production
D. Tetrology of Fallot

Answer 5

Answer: A

The most common cause of
respiratory distress in preterm
neonates is the respiratory
distress syndrome (RDS) also
known as hyaline membrane
disease. The syndrome is
responsible for 50 - 75% of
deaths in preterm neonates. It
is the result of deficient
production and secretion of
surfactant, which is produced
by type II pneumocytes.
Mature levels of surfactant
are not present until 35 weeks
of gestation.

Question 6

Electrocardiographic changes associate with the third trimester of pregnancy include:

A. R axis deviation
B. First degree AV Block
C. Left axis deviation
D. Sinus Bradycardia

Answer 6

Answer: C

Elevation of the diaphragm
shifts the heart position in the
chest resulting in the
appearance of an enlarged
heart on a plain chest film and
in left axis deviation and T
wave changes on the
electrocardiogram.

Question 7

You are asked to evaluate a 31 year old G3P2 woman in for a repeat C/S. Her PMH includes 2 previous C/s. She has been laboring for the previous 7 hours with little progress despite an oxytocin infusion. During the interview, she complains of sudden severe continuous abdominal pain radiating to her left shoulder. These symptoms are most consistent with:

A. Preeclampsia
B. Abrupto Placentae
C. Uterine Rupture
D. Placenta Previa

Answer 7

Answer C

Uterine rupture is often
heralded by severe abdominal
pain, referred to the shoulder
due to subdiaphragmatic
irritation by intra-abdominal
blood. Uterine rupture is
associated previous uterine
scars and excessive oxytocin
stimulation. Current
recommendations discourage
VBAC in women with two or
more previous uterine
incisions.

Question 8

A 9 year old patient with a history of cerebral palsy is scheduled for release of contractures of the achilles tendons. The patient is receiving phenytoin for control of seizures. Anesthetic considerations for these patients include:

A. increased sensitivity to NDMR
B. Likelihood of GERD increased
C. possibility of severe hyperkalemia with use of succs
D. Avoidance of volatile anesthetics because of an increased incidence of MH in these patients

Answer 8

Answer: B

Management of anesthesia in
children with cerebral palsy
includes tracheal intubation
because of the propensity for
GERD and poor function of
laryngeal and pharyngeal
reflexes.

There is no increase
in the incidence of MH in
these patients and the use of
volatile anesthetics has been
shown to be safe.

Patients
receiving anticonvulsants may
be more resistant to the
effects of nondepolarizing
relaxants.

Despite the skeletal
muscle spasticity,
succinylcholine does not
produce abnormal potassium
release in these patients.

Question 9

The most common morbidity encountered in obestetrics is:
A. Severe spesis
B. severe preeclampsis
C. HELLP syndrome
D. Severe hemorrhage

Answer 9

Answer: #1: Severe hemorrhage, #2: Severe preeclampsia

Question 10

As compared to RA, the risk of maternal death from GA is approximately:

A. the same
B. three times higher
C. Eight times higher
D. 16x higher

Answer 10

Answer D

Question 11

In the fetus, blood entering the RA from the IVC is preferentially directed to the:

A. Ductus Arteriosus
B. RV
C. Foramen Ovale
D. Ductus Venousus

Answer 11

Answer: C

Right atrial anatomy
preferentially directs blood
from the inferior vena cava
through the foramen ovale
into the left atrium.

Question 12

Functional residual capacity is decreased in the neonate as a result of:

A. Increased lung compliance and decreased chest wall compliance
B. Decreased lung compliance and increased chest wall compliance
C. Increased lung compliance and increased chest wall compliance
D. Decreaed lung compliance and decreased chest wall compliance

Answer 12

answer: B

The small and limited number
of alveoli in neonates and
infants reduces lung
compliance; in contrast, their
cartilaginous rib cage makes
their chest wall very
compliant. The combination
of these two characteristics
promotes chest wall collapse
during inspiration and
relatively low residual lung
volumes at expiration.

Question 13

Renal changes seen during pregnancy include a reduction:

A. Plasma levels of renin and aldosterone
B. The tubular threshold for glucose and amino acids
C. Glomerular filtration
D. Renal plasma flow

Answer 13

B

the tubular threshold for
glucose and amino acids.
Renal vasodilation increases
renal blood flow, glomerular
filtration and renal plasma
flow. Increased renin and
aldosterone levels promote
sodium retention. A decreased
renal tubular threshold for
glucose and amino acids is
common and often results in
mild glycosuria or
proteinuria.

Question 14

Post-intubation laryngobracheobronchitis (croup) is most commonly seen in children of:

A. 0 - 1 years of age
B: 1 - 4 years of age
C: 4 - 7 years of age
D: 7 - 9 years of age

Answer 14

Answer: B

Post-intubation croup is due
to glottic or tracheal edema
and is associated with early
childhood (ages 1 - 4),
repeated intubation attempts,
large endotracheal tubes,
prolonged surgery, head and
neck procedures and
excessive movement of the
endotracheal tube. Nebulized
racemic epinephrine is an
effective treatment.

Question 15

Of the following, the lowest degrees of placental drug transfer occurs with the use of:

A. Bupivacaine
B. Chloroprocaine
C. Lidocaine
D. Ropivacaine

Answer 15

Answer: B

Chloroprocaine has the least
placental transfer because it is
rapidly broken down by
plasma cholinesterase in the
maternal circulation.

Question 16

The appropriate ETT diameter for a full term neonate is approximately:

A. 2.0 mm
B. 3.0 mm
C. 4.0 mm
D. 4.5 mm

Answer 16

Answer: B
For pediatric patients, the
appropriate diameter of the
endotracheal tube can be
estimated by the formula:
Tube diameter = 4 + (age/4)

Exceptions include premature
neonates (2.5 - 3.0 mm) and
full-term neonates (3.0 - 3.5
mm).

Question 17

Pain during the latent phase of labor is usually confined to dermatomes:

A. T11-T12
B. L1 - L2
C. L3 - L4
D. L5 - S1

Answer 17

Answer: T11 - T12

Pain during the first stage of
labor is mostly visceral pain
resulting from uterine
contractions and cervical
dilatation. It is usually
initially confined to the T11 -
T12 dermatomes during the
latent phase, but eventually
involves the T1- - L1
dermatomes as the labor
enters the active phase.

Question 18

A 12 year old patient is scheduled for an excision of a sellar craniopharyngioma. Suspected preoperative lab abnormalities in this patient include:

A. A decreased T4 level with an elevated thyrotropin level
B. An elevated plasma cortisol level
C. Hypernatremia
D. An elevated growth hormone

Answer 18

C

Craniopharyngioma is the
most common intracranial
tumor of nonglial origin in the
pediatric population. Because
the tumor can affect the
pituitary, endocrine
dysfunction is common.
Secondary hypothyroidism,
growth hormone deficiency,
secondary hypocortisolism
and diabetes insipidus should
all be suspected. Diabetes
insipidus can present
preoperatively as
hypernatremia, but may also
be seen 4 - 6 hours
postoperatively, due to
surgical damage to the
pituitary.

Question 19

As compared to the non-pregnant patient, the incidence of pulmonary aspiration of gastric contents in the OB pt is

A. Approximately equal if cricoid pressure is applied
B. Twice as great
C. 4 to 5x greater
D. 8 - 10 x greater

Answer 19

Answer: C

4-5x greater
Pulmonary aspiration of
gastric contents is 4 - 5 times
greater in the obstetric patient
with an incidence of 1:400 -
500 as compared to an
incidence of 1:2000 in the
non-pregnant patient.

Question 20

At 20 weeks gestation, frequently found changes in Heart sounds include:

A. loss of split of the first heart sound
B. Grade I or II diastolic murmur
C. Presence of a third heart sound
D. All of the above

Answer 20

Answer: C

Presence of third heart sound
Several changes in heart
sounds occur during
pregnancy. Early closure of
the mitral valve may cause a
split first heart sound. A third
heart sound can be heard in
most women by 20 weeks’
gestation. A benign grade I or
II systolic murmur is also
common. Diastolic murmurs
are pathologic.

Question 21

A 24 year old patient presents to the ER in labor with contractions occurring every 4 minutes. She is at 32 weeks. Pharmacologic inhibition of uterine contractions is accomplished with:

A. IV Calcium chloride therapy
B. IV Betamethasone therapy
C. IV Metoprolol therapy
D. IV Ritodrine Therapy

Answer 21

Answer: D

The most commonly used
tocolytics are β2-agonists
(ritodrine or terbutaline) and
magnesium. Although
betamethasone may be given
to induce fetal production of
surfactant, it is not effective
as a tocolytic agent. More
recently, oxytocin antagonist,
atosiban, has show
effectiveness in patients of
greater than 28 weeks
gestation.

Question 22

The position of the larynx in a Neonate is:

A. C2
B. C4
C. C6
D. C8

Answer 22

Answer: C4 (B)

Neonates and infants have a
proportionately larger head
and tongue, narrow nasal
passages, an anterior and
cephalad larynx (at vertebral
level C4 versus C6 in adults),
a long epiglottis and a short
trachea.

Question 23

Clinically significant placental drug transfer has NOT been shown to occur with the use of:

A. Ephedrine
B. Labetalol
C. Glyco
D. Metoclopramide

Answer 23

Answer: C

Question 24

A 38-postconception week neonate is scheduled for an emergent repair of an incarcerated inguinal hernia. The patient was delivered at 34 weeks of gestation. Anesthetic management of this patient should include:

A. Maintenance of Arterial PaO2 > 100 mmHg
B. Permissive Hypercapnia to reduce barotrauma to lungs
C. Maintenance of oxygen saturation between 89-94%
D. The use of 3% NaCl for fluid replacement

Answer 24

Answer: C

In this preterm neonate there
exists a substantial risk for the
development of retinopathy of
prematurity. Because the
optimal intraoperative oxygen
saturation for these infants is
not known, it is prudent to
limit oxygen supplementation
during the period of retinal
vascularization (up to 44
weeks postconception).
Efforts should be made to
maintain PaO2 between 50 -
80 mmHg and PaCO2
between 35 - 45 mmHg. This
results in a pulse oximetry
target of 89 - 94%.

Question 25

Morphine is infrequently used as an analgesic during labor because of at equianalgesic doses, it appears to cause: A. A higher incidence of fetal seizures compared to fentanyl B. A higher incidence of fetal respiratory depression as compared to fentanyl C. A greater loss of fetal thermal regulation as compared to fentanyl D. A higher incidence of fetal bronchospasm as compared to fentanyl

Answer 25

Answer: B Morphine is seldom used for maternal analgesia because in equianalgesic doses it appears to cause greater respiratory depression in the fetus than meperidine or fentanyl.

Question 26

A 10 kg child is scheduled for a resection of a skin lesion of the right thigh. The anesthetic plan calls for an LMA. The appropriate size for this patient is: A. 1 B. 2 C. 3 D. 4

Answer 26

LMA 2

Question 27

Pulmonary Aspiration during induction of GA in the pregnant woman is more likely the result of: A. the posterior displacement of the stomach by the uterus B. Placental gastrin secretion C. Increased intragastric pressure D. Progesterone-induced increase in LES

Answer 27

B

Question 28

Factors complicating the airway management of the patient with trisomy 21 include A. Microglossia B. Prognathia C. Hypertoniciy of master muscles D. Occipitoatlantoaxial instability

Answer 28

Answer: D Trisomy 21 or Down syndrome is the most common human chromosomal syndrome. Airway management in these patients can be difficult due to macroglossia, micrognathia, narrow hypopharynx and muscular hypotonia. There is also a risk of spinal cord compression due to occipitoatlantoaxial instability.

Question 29

Pathophysiologic events associated with preeclampsia: A. production imbalance between prostacyclin and thromboxane A2 B. Intravascular volume expansion C. Decreased vascular sensitivity to catecholamines D. Thrombocytosis

Answer 29

Answer: A Pregnancy-induced hypertension (PIH) encompasses a range of disorders, including gestational hypertension, preeclampsia and eclampsia. Three principal mechanisms serve as the etiology of PIH. These mechanisms are: abnormal sensitivity of vascular smooth muscle to catecholamines, placental vasculitis, and an imbalance in the production of vasoactive prostaglandins (thromboxane A2 and prostacyclin).

Question 30

Treatment of cardiac toxicity secondary to unintentional intravascular bupivacaine should include: A. Control of arrhythmias with IV lidocaine B. Control of arrhythmias with IV verapamil C. Avoidance of cardioversion D. Administration of 20% lipid solution

Answer 30

answer: D 20% lipid solution Cardiac toxicity from bupivacaine may be difficult to treat. Hyperventilation with oxygen should be immediately instituted. Ventricular dysrhythmias may need large and multiple doses of electrical cardioversion, epinephrine, vasopressin and amiodarone. The use of calcium channel blockers is not recommended. The administration of a 20% lipid solution at an initial dose of 4 mL/kg has been found to improve survival.

Question 31

In children under 5 years of age, the narrowest point of the airway is the: A. Rina GLottis B. Thyroid cartilage C. Cricoid cartilage D. Hyoid cartilage

Answer 31

Answer: C

Question 32

In the parturient, uterine hypertonic has been associated with the use of large induction doses of: A. Thiopental B. Propofol C. Etomidate D. Ketamine

Answer 32

Answer: Ketamine Uterine hypertonus may occur with ketamine at doses > 2 mg/kg.

Question 33

A 12kg child is scheduled for repair of an inguinal hernia. The patient had respiratory infection 2 weeks ago but now has full resolution of symptoms. At this time, the patient is at increased periop risk of: A. Bronchospasm B. Laryngospasm C. Hypoxia D. All of the aboce

Answer 33

Answer: D A viral infection within 2 - 4 weeks before general anesthesia and endotracheal intubation appears to place the child at risk for perioperative pulmonary complications such as bronchospasm (10 fold), laryngospasm (5 fold), hypoxia and atelectasis.

Question 34

At term, pseudocholinesterase activity is: A. increased by 10% B. increased by 30% C. Decreased by 10% D. Decreased by 30%

Answer 34

Answer: Decreased by 30%

Question 35

Kernicterus has been reported after the IV administration of drugs to neonates which contain the preservative: A. Metabisulfate B. P-amino Benzoic Acid C. EDTA D. Benzyl Alcohol

Answer 35

Answer: Benzyl Alcohol Benzyl alcohol has been implicated in causing kernicterus by displacing bilirubin from albumin and facilitating its entry into the brain. Certain preparations of propofol and normal saline flush can contain benzyl alcohol and should be avoided in the neonate.

Question 36

Treacher Collins syndrome: A. Results in anterior displacement of the tongue B. Results in mandibular hyperplasia C. Is often associated with other craniofacial abnormalities such as cleft palate D. Follow an autosomal recessive inheritance pattern

Answer 36

Answer: C craniofacial abnormalities such as cleft palate. Treacher-Collins syndrome is the most common of the mandibulofacial dysostoses. Inheritance is as an autosomal dominant trait. Hypoplasia of the mandible with posterior displacement of the tongue (glossoptosis) can result in early airway problems. Treacher-Collins syndrome is associated with cleft palate, ventricular septal defect, and gross deformites of the external ear canals and ossicular chain. These patients present extreme difficulty with airway management and facilities for surgical airway placement should be part of the anesthetic plan.

Question 37

Nonsteroidal anti-inflammatory agents, such as ketorlac, are not recommended as analgesics during labor because they are associated with: A. delayed closure of the ductus arterioles B. Maternal and fetal respiratory depression C. Suppression of uterine contractions D. Impaired placental oxygen transfer to the fetus

Answer 37

Answer: C Suppression of uterine contractions Nonsteroidal antiinflammatory agents are not recommended because they suppress uterine contractions and promote closure of the fetal ductus arteriosus.

Question 38

In the patient with pregnancy induced HTN, epidural analgesia during labor has been associated with A. Increased maternal catecholamine levels B. Improved uterine placental blood flow C. Increased uterine artery vasospasm D. Fetal distress

Answer 38

Answer: B Epidural analgesia is the preferred technique for labor analgesia in the patient with PIH if not contraindicated by coagulopathy. Epidural analgesia reduces maternal catecholamine levels and facilitates blood pressure control. Epidural analgesia improves intervillous blood flow thus improving uteroplacental performance and fetal well-being.

Question 39

In neonates and infants, variations in cardiac output are largely the result of A. SVR B. SV C. Barorecpetor reflex D. Heart Rate

Answer 39

Answer: D SV is fixed due to poorly developed and noncompliant left heart. The cardiac output is therefore very dependent on heart rate. Additionally, sympathetic nervous system and baroreceptor reflexes are not fully mature and less able to compensate for changes in blood pressure.

Question 40

You are asked to evaluate a 26F complaining of headache following an uneventful vaginal delivery with continuous epidural analgesia. Likely causes of the headache: A. injection of significant amount of air during epidural placement B. Placement of a multihued epidural catheter C. Use of 0.25% bupivacaine for initial injection D. Use of fentanyl in the epidural infusion

Answer 40

Answer: A Headache frequently follows unintentional subdural puncture in parturients. However, a self-limited headache may occur without dural puncture; in such instances, injection of significant amounts of air into the epidural space may be responsible.

Question 41

At term, Maternal RBC mass has: A. decreased by up to 15% B. Increased by up to 10% C. Increased by up to 20% D. Increased by up to 50%

Answer 41

Answer: C

Question 42

The beginning of second stage of labor is defined by: A. presence of full cervical dilation B. Presence of active phase of labor C. Rupture of amniotic sac D. Presence of uterine contractions occurring at a frequency of > 2 min

Answer 42

Answer: A The second stage begins with full cervical dilatation, is characterized by fetal descent, and ends with complete delivery of the fetus.

Question 43

The most common metabolic abnormality in the neonate is: A. Hypoglycemia B. Hyponatremia C. Hypokalemia D. Hypoclacemia

Answer 43

Answer: A Hypoglycemia is the most common metabolic problem occurring in the neonate. Inadequate glycogen stores and deficient gluconeogenesis are important factors in the newborn's susceptibility to hypoglycemia. The incidence is highest in small-for- gestational age neonates and in neonates of diabetic mothers.

Question 44

During pregnancy, the level of which of the following clotting factors may be decreased: A. VII B. VIII C. XI D. XII

Answer 44

Answer: C. Pregnancy is associated with a hypercoagulable state. Fibrinogen and factors VII, VIII, IX, X and XII concentrations all increase; only factor XI may decrease.

Question 45

An increase incidence of malignant hyperthermia is seen in children with: A. Central core disease B. Duchenne MD C. Malignant neuroleptic syndrome D. Cerebral Palsy

Answer 45

Answer A Linkage of MH with other diseases has been problematic: only central core disease appears to be truly linked. In Duchenne's muscular dystrophy, the balance of opinion has shifted from an association with MH to an anesthesia-induced rhabdomyolysis. Cerebral palsy and malignant neuroleptic syndrome are not associated with an increased incidence of MH, although malignant neuroleptic syndrome may mimic MH and is part of the differential diagnosis.

Question 46

Pain relief during the second stage of labor requires neural blockade from T10 to: A. S1 B. S2 C. S3 D. S4

Answer 46

Answer: D Sensory innervation of the perineum is provided by the pudendal nerve (S2 - S4) so pain during the second stage of labor involves the T10 - S4 dermatomes.

Question 47

An 8kg infant is to receive GA with ETT. Current recommendations concerning preop fasting of this patient include: A. NPO for 6-8H prior to surgery B. Clear fluids can be given up to 1H prior to surgeyr C. Breast milk may be given up to 4H prior to surgery D. SOlid foods may be given up to 3H prior to surgery

Answer 47

Answer: C breast milk may be given up to 4 hours prior to surgery. Current fasting recommendations for children include: Solids are prohibited within 6 - 8 hours of surgery, formula within 6 hours, breast milk within 4 hours and clear liquids within 2 hours of surgery.

Question 48

Maternal mortality associated with AFE is: A. 10 - 20% B. 25 - 40% C. 50 - 75% D. > 80%

Answer 48

Answer: D

Question 49

At term, commonly found changes in maternal BP include: A. little change in systolic pressure with decreased diastolic pressure B. Increased SBP and decreased DBP C. Decreased SBP and DBP D. Increased SBP and DBP

Answer 49

Answer: A Overall, at term, systolic blood pressure changes little. A decrease in diastolic blood pressure of 15 mmHg may occur resulting in a decrease in mean pressure and an increase in pulse pressure.

Question 50

You are called to deliver anesthesia to an emergent C/S in a 28F 100kg female with umbilical cord prolapse. After IV induction, several attempts at ETT are unsuccessful. The most appropriate management at this time should be: A. Transtracheal jet ventilation B. Placement of LMA while maintaining cricoid pressure C. awakening the pt and placement of epidural catheter D. Obtaining a surgical airway

Answer 50

Answer: B In the face of severe fetal distress, general anesthesia is indicated. If initial attempts at intubation fail, ventilation should be attempted with either the face mask or LMA, while continuing cricoid pressure.

Question 51

Upon delivery of a 3.2kg male, the neonate is noted to be cyanotic with a scaphoid abdomen. Auscultation of the chest reveals bowel sounds in the left hemithorax. Management of the infant should include: A. Decompression of the stomach with a gastric tube B. PPV by mask with 100% FIO2 C. Awake intubation and ventilation with 100% FIO2 and increased PIP to inflate left lung D. All of the above

Answer 51

Answer: A decompression of the stomach with a orogastric tube This neonate's signs and symptoms are consistent with congenital diaphragmatic hernia. Immediate treatment should include decompression of the stomach and the administration of supplemental oxygen. Positive pressure by mask should be avoided as it may cause stomach distention and further compromise pulmonary function. Awake intubation should be performed, but positive airway pressures should not exceed 25 - 30 mmHg as it can precipitate damage to the normal lung and pneumothorax.

Question 52

The greatest strain on the maternal heart occurs: A. during the active phase of labor B. immediately after delivery C. during the latent phase of labor D. during the second stage of labor

Answer 52

Answer: B The greatest strain on the heart occurs immediately after deilvery, when intense uterine contraction and involution suddenly relieve inferior vena caval obstruction and increse cardiac output as much as 80% above prelabor values.

Question 53

Intraop heat loss is greater in neonates than adults as a result of: A. A larger surface area:core ratio in the neonate B. Increased skin thickness in the neonate C. Increased SQ adipose tissue in the neonate D. An increased shivering response in neonates

Answer 53

Answer: A Pediatric patients have a larger surface area per kilogram than adults. Thinner skin and a lower fat content also contribute to greater heat loss in the neonate. Shivering is not an important method of thermogenesis in the neonate.

Question 54

During pregnancy, the level of which of the following hormones steadily increases? A. Free T4 B. Insulin C. TSH D. Increased T3

Answer 54

Answer: Insulin

Question 55

In children with R to L intracardiac shunting, inhalation induction is expected to be: A. slower than healthy children B. Faster than healthy children C. Unaffected by the presence of shunt D. Faster than in healthy children when very soluble agents are used

Answer 55

Answer: A A right-to-left shunt slows the inhaled induction of anesthesia because anesthetic concentration in the arterial blood increases more slowly. A left-to-right shunt has little effect since the decreased delivery of anesthetic to the target tissues negates the increased uptake with this type of shunt

Question 56

The administration of a beta2 agonist to the laboring parturient will cause: A. increase in uterine tone B. Decrease in uterine tone C. decrease in placental blood flow D. an acceleration to the second stage of labor

Answer 56

Answer: B Decrease in uterine tone. Uterine muscle has both α- and β-receptors. α1-Receptor stimulation causes uterine contraction, whereas β2- receptor stimulation produces relaxation..

Question 57

A 26F with a history of mitral stenosis is in labor. Beneficial effects of epidural anesthesia in this patient include: A. A mild increase in PVR B. mild decrease in preload C. Reduced incidence of pain-induced maternal tachycardia D. all of the above

Answer 57

Answer: C reduced incidence of pain- induced maternal tachycardia,. Mitral stenosis is the most common type of cardiac valvular defect seen in pregnant patients. Epidural analgesia during labor and delivery reduce pain-induced tachycardia allowing more time for left ventricular filling. Preload should be maintained and causes of pulmonary vasoconstriction (hypoxia) should be avoided.

Question 58

At term, the MAC of inhaled agents is: A. Increased by 20% B. Increased by 40% C. Decreased by 20% D. Decreased by 40%

Answer 58

Answer: D

Question 59

The most common congenital cardiac abnormality in infants and children is; A. ASD B. VSD C. PDA D. Tetralogy of Fallot

Answer 59

Answer: B Ventricular septal defect is the most common congenital cardiac abnormality, constituting approximately 35% of all congenital cardiac abnormalities. But Tetraology of Fallot is the most common CYANOTIC cardiac congenital anomalies

Question 60

Breech positions A. have little effect on fetal morbidity if vaginal delivery is accomplished B. Are commonly seen with post-mature fetus C. Are associated with increased incidence of cord prolapse D. Complicate about 10% of pregnancies

Answer 60

Answer: C Breech presentations complicate 3 - 4% of deliveries and significantly increase both maternal and fetal morbidity and mortality rates. The most common cause is prematurity. Breech presentation also increases the incidence of cord prolapse to 10%.

Question 61

A 3.2 kg neonate is scheduled for a polyoromyotomy. The estimated blood volume of the neonate is approximately: A. 154 mL B. 280 mL C. 332 mL D. 401 mL

Answer 61

Answer: B Full-term neonates have a blood volume of 85 - 90 mL/kg. In this neonate the EBV = 85 - 90 mL/kg x 3.2 kg = 272 - 288 mL.

Question 62

Low dose (< 0.75 MAC) of volatile anesthetic agents have been shown to: A. Cause uterine artery vasoconstriction B. increase myometrial muscle activity C. Cause little changes in the effects of oxytocin in the uterus D. Cause uterine atony

Answer 62

Answer: C Isoflurane, sevoflurane and desflurane depress uterine activity equally at equipotent doses. Low doses (< 0.75 MAC) of these agents, however, do not interfere with the effect of oxytocin on the uterus. Higher doses can result in uterine atony and increase blood loss at delivery. Nitrous oxide has minimal if any effects.

Question 63

In order to maintain euglycemia in the neonate, it is recommended that IV fluid ternary include glucose infused at a rate of: A. 3 - 5 mg/kg/hr B. 3 - 5 mg/kg/min C. 6-10 mg/kg/hr D. 6 - 10 mg/kg/min

Answer 63

Answer: B Neonates require 3 - 5 mg/kg/min of glucose infusion to maintain euglycemia; premature neonates require 5 - 6 mg/kg/min.

Question 64

At term, uterine blood flow represents approximately A. 5% of CO B. 10% of CO C. 20% of CO D. 30% of CO

Answer 64

Answer: B There is an increase in cardiac output of approximately 40% at term and about 10% or 600 - 700 mL/min represents the uterine blood flow.

Question 65

The most common form of tracheoesophageal fistula consists of: A. A blind upper esophageal pouch with no fistula between the esophagus and the tracheal B. Blind upper esophagus pouch with fistula between the trachea and distal esophagus C. Fistula between a blind upper esophagus pouch and trachea D. Fistula between the trachea and an otherwise normal esophagus

Answer 65

Answer: B Approximately 86% of tracheoesophageal fistulas are of Type III B, consisting of a blind upper esophageal pouch and a tracheal fistula connecting to the distal esophagus. Anesthetic management ideally consists of an awake intubation with placement of the ETT distal to the fistula, but above the carina.

Question 66

In contrast to the single-hole epidural catheter, the multihued catheter A. Requires a shorter depth of insertion B. Is associated with lower incidence of unilateral block C. Increases the incidence of false-negative aspiration for intravascular placement

Answer 66

Answer: B Use of a multiholed catheter appears to be associated with fewer unilateral blocks and greatly reduces the incidence of false-negative aspiration for intravascular catheter placement. Advancing a multiholed catheter 7 - 8 cm into the epidural space appears to be optimal for obtaining adequate sensory levels.

Question 67

Hyoercyanotic attacks associated with Tetrology of Fallot are best treated with: A. Epinephrine B. Isoproterenol C. Phenylephrine D. Nitroglycerin

Answer 67

Answer: Phenylephrine Treatment of hypercyanotic attacks is influenced by the cause of the pulmonary outflow obstruction. When symptoms reflect a dynamic infundibular obstruction, beta-blockers are appropriate treatment. If the cause is decreased systemic vascular resistance, treatment is intravenous fluids and/or phenylephrine. Sympathomimetic drugs with β-agonistic properties or vasodilators should not be used.

Question 68

In the absence of drug administration, sustained decreased baseline variability in the fetal heart rate suggests: A. Normal progress from latent to active phase of labor B. Normal progress from first to second stage of labor C. Full development of neuronal pathways of the vagus nerve D. Fetal distress

Answer 68

Answer: D Fetal heart rate varies 5 to 20 bpm in the normal fetus. Fetal distress due to arterial hypoxemia, acidosis or CNS damage is associated with minimal to absent beat-to- beat variability.

Question 69

Compared to a 3 month old, the MAC of desflurane required to anesthetize a full term neonate is A. 10% greater B. 25% greater C. 10% Less D. 25% Less

Answer 69

Answer: D Full-term neonates require lower concentrations of volatile anesthetics than do infants 1 - 6 months of age. The MAC is about 25% less in neonates than in infants. Furthermore, MAC in preterm neonates is less than full-term neonates. MAC steadily increases until 2 - 3 months of age and then steadily declines with age.

Question 70

The greatest risk factor for placenta previa is: A. Prematurity B. Polyhydraminos C. Nullparity D. Previous C/sections

Answer 70

Answer: D The greatest risk factor for placenta previa is previous cesarean section. Other risk factors include previous uterine myomectomy, multiparity, advanced maternal age and a large placenta.

Question 71

Obstruction of the IVC by the enlarging uterus results in: A. decreased blood volume in the epidural venous plexus B. decreased spinal CSF volume C. Increased potential volume of the epidural space D. Decreased epidural space pressure

Answer 71

Answer: B Obstruction of the inferior vena cava by the enlarging uterus distends the epidural venous plexus and increases epidural blood volume. The latter has three major effects: (1) decreased CSF volume, (2) decreased potential volume of the epidural space and (3) increased epidural space pressure.

Question 72

During Labor, continuous epidural analgesia with 0.1% bupivacaine with fentanyl 5 mcg/ mL has been associated with: A. increased risk of C/s B. increased rate of forceps deliver C. Decreasd efficacy of oxytocin D. Minimal or no change in duration of labor

Answer 72

Answer D Current techniques employing dilute combinations of local anesthetic and opioid for epidural analgesia do not appear to prolong labor or increase the likelihood of cesarean section.

Question 73

As compared to patients with gastroschisis, patients with omphalocele: A. rarely have any other congenital defects B. lack a peritoneal covering of the abdominal contents C. Have a midline defect at the base of the umbilical cord D. are usually delivered after 42 weeks

Answer 73

Answer: C have a midline defect at the base of the umbilical cord. Omphalocele manifests as external herniation of abdominal viscera through the base of the umbilical cord. The abdominal contents are contained within a sac formed from the peritoneal membrane without overlying skin. Omphalocele is associated with a 75% incidence of other congenital defects. Approximately 33% of neonates with omphaloceles are preterm.

Question 74

During pregnancy, uterine blood flow is directly proportional to A. difference between arterial and venous pressures B. Uterine vascular resistance C. Uterine venous pressure D. Degree of endogenous catecholamines

Answer 74

Answer: A Uterine blood flow is directly proportional to the difference between uterine arterial and venous pressures, but inversely proportional to uterine vascular resistance. Stress-induced release of endogenous catecholamines can cause uterine vasoconstriction and reduce uterine blood flow.

Question 75

A 3 month old is scheduled for correction of tetralogy of Fallot. Induction of anesthesia is best accompanied by: A. Thiopental B. Isoflurane C. Desflurane D. Ketamine

Answer 75

Answer: Ketamine Induction of anesthesia in patients with tetralogy of Fallot is often accomplished with intravenous or intramuscular ketamine. The onset of anesthesia after ketamine injection may be associated with improved oxygenation, presumably reflecting increased pulmonary blood flow due to ketamine-induced increases in systemic vascular resistance.

Question 76

In the parturient, the most common complication of regional anesthesia is A. unintentional intravascular injection B. unintentional intrathecal Injection C. HoTN D. Postural puncture headache

Answer 76

Answer: C Hypotension is the most common complication of regional anesthesia. It is primarily due to decreased sympathetic tone and is greatly accentuated by aortocaval compression.

Question 77

During pregnancy, the P-50 curve of maternal hemoglobin: A. increases to about 30 mmHg B. Increases to about 40 mmHg C. Remains unchanged D. Decreases to about 23 mmHg

Answer 77

Answer: A During pregnancy, the P-50 for the maternal hemoglobin increases from 27 to 30 mmHg; the combination of this and increased cardiac output enhances oxygen delivery to tissues and placenta.

Question 78

Placenta Accreta: A. is associated with massive hemorrhage from manual extraction of the placenta B. Is rarely seen in patients with placenta previa C. Involves invasion of the placenta into the myometrium D. Is not associated with previous C/s

Answer 78

Answer: A is associated with massive hemorrhage from manual extraction of the placenta. Placenta accreta is an adherent placenta that has not invaded the myometrium. Massive hemorrhage may occur when removal of the placenta is attempted after delivery. Risk factors include placenta previa and previous cesarean delivery.

Question 79

The heart rate racing below is: A. suggestive of fetal distress B. Suggestive of fetal head compression C. Suggestive of fetal cod compression D. A reassuring tracing

Answer 79

Answer: A Suggestive of fetal distress. This tracing is indicative of late decelerations. Late decelerations are characterized by the slowing of the fetal heart rate that begins 10 - 30 seconds after the onset of uterine contractions. Late decelerations are associated with fetal distress.

Question 80

As compared to an adult, the alveolar uptake of inhalationall anesthetics is greater in the neonate as a result of: A. A greater MV to FRC ratio in the neonate B. the smaller cardiac output C. Increased blood solubility of the agent in the neonate D. Increased dead space to shunt ratio in the neonate

Answer 80

Answer: A a greater minute ventilation to FRC ratio in the neonate. Uptake of inhaled anesthetics is more rapid in infants than in older children or adults. This accelerated uptake most likely reflects the infant's high alveolar ventilation relative to functional residual capacity

Question 81

Complications associated with oxytocin administration include: A. Maternal water intoxication B. Uterine Atony C. hypertension with rapid infusion D. All of the above

Answer 81

Answer: C Complications of oxytocin administration include fetal distress due to hyperstimulation, uterine tetany and maternal water intoxication. Rapid intravenous infusion can also cause transient systemic hypotension due to relaxation of vascular smooth muscle.

Question 82

Anesthetic care of the neonate undergoing correction for gastroschisis should include: A. Maintenance of adequate hydration with 4 mL/kg/hr of crystalloid solution B. The use of nitrous oxide to hasten emergence and extubation C. The avoidance of of muscle relaxation D. Periop hydration with both crystalloid and colloid solutions

Answer 82

Answer: D preoperative hydration with both crystalloid and colloid solutions. Preoperative fluid management will require 2 - 4 times the usual daily maintenance (8 - 16 mL/kg/hour) These neonates experience considerable protein loss. To maintain normal oncotic pressures, protein containing solutions should constitute approximately 25% of the replacement fluids. Repair of large defects will require maximal muscle relaxation both intraoperatively and postoperatively. Nitrous oxide is avoided because of its ability to diffuse into the intestinal tract making closure more difficult.

Question 83

The sensory level required to produce adequate anesthesia for C-section is: A. T4 B. T6 C. T8 D. T10

Answer 83

Answer: A Cesarean section requires a T4 sensory level. Because of the high sympathetic blockade, all patients should receive a 1000 - 1500 mL bolus of lactated Ringer's prior to neural blockade.

Question 84

Epiglottitis is: A. effectively treated with nebulized racemic Epi B. Best managed with an awake intubatiojn C. most commonly secondary to viral infection of the trachea D. Associated with inflammation of all supraglottic structures

Answer 84

Answer: D Acute epiglottitis is a bacterial infection affecting all supraglottic structures. In children, it is best managed with a slow inhalational induction followed by intubation. Preparedness for emergent tracheostomy is essential.

Question 85

Vascular components of the umbilical cord include: A. One umbilical artery and one umbilical vein B. One umilical artery and two umbilical veins C. Two umbilical arteries and one umbilical vein D. Two umbilical arteries and two umbilical veins

Answer 85

Answer: C Fetal blood flow within the placenta is derived from the umbilical cord via two umbilical arteries and returns to the fetus via a single umbilical vein.

Question 86

The diagram below is consistent with: A. Normal neonatal anatomy B. Tetralogy of Fallot C. Transposition of the great vessels D. Truncus arteriosus

Answer 86

Answer: C

Question 87

Five minutes after delivery of a 3.25kgM, the following is observed: Pulse: 122 Actively Crying Active flexion and extension with stimulation and acrocyanosis What is his Apgar score? A. 7 B. 8 C. 9 D. 10

Answer 87

Answer: 9

Question 88

Respiratory parameters that are increased during pregnancy include: A. Airway resistance B. Tidal Volume C. FRC D. PaCO2

Answer 88

Answer: B Oxygen consumption and minute ventilation progressively increase during pregnancy. Both tidal volume and rate increase. PaCO2 decreases and PaO2 increases slightly. Airway resistance declines about 35% during pregnancy and FRC is reduced by approximately 20%.

Question 89

Carbaprost: A. Causes uterine relaxation B. Should only be administered IM C. Should only be given prior to delivery D. Is effective in reducing need for C/S

Answer 89

Answer: B Carboprost tromethamine is a synthetic analogue of prostaglandin F2 that stimulates uterine contraction. it is often used to treat refractory post partum hemorrhage. As with methergine, it should be administered only intramuscularly.

Question 90

The blood/gas coefficient for volatile anesthetics: A. Are greater in the neonate than the adult B. Are less in the neonate than the adult C. Remain unchanged regardless of age D. Are increased in preterm neonates but normal in full term neonates

Answer 90

Answer: B The blood/gas coefficients of volatile anesthetics are lower in neonates than in adults, resulting in even faster induction times and potentially increasing the risk of overdosing.

Question 91

In contrast to placenta previa, abruptio placentae: A. Usually occurs after 32 weeks of gestation B. Is associated with abdominal pain C. Poses little risk to the developing fetus D. Is not associated with coagulopathy

Answer 91

Answer: B The signs and symptoms of abruptio placentae are variable, but abdominal pain is always present, whereas placenta previa is associated with painless vaginal bleeding. Shock, coagulopathy, acute renal failure and fetal distress are also associated with abruptio placentae. Abruptio placentae is usually seen earlier in the pregnancy, after 20 weeks of gestation.

Question 92

Metabolic defects commonly seen in infants with pyloric stenosis include: A. Hypokalemia B. Acidosis C. Hyperchloremia D. Hypernatremia

Answer 92

A. Hypokalemia Persistent vomiting results in the progressive loss of gastric fluid, which contains sodium, potassium, chloride and hydrogen. Renal pH compensation causes further loss of potassium. These patients are dehydrated, hypokalemic and alkalotic. Hyponatremia may also be present.

Question 93

Volatile anesthetic agents cross the placenta and enter fetal circulation via A. Breaks in the placental membrane B. Bulk Flow C. Pinocytosis D. Diffusion

Answer 93

Answer: D Placental exchange can occur by one of five mechanisms: diffusion, bulk flow, active transport, pinocytosis and breaks in the placental membrane. Most drugs used in anesthesia have molecular weights well under 1000 and consequently can diffuse across the placenta.

Question 94

Neonatal changes occur upon delivery include: A. Lung expansion by creation of negative 40 - 60 cmH2O intrathoracic pressure B. Anatomic closure of the ductus arteriosus C. Increased PVR secondary to lung resistance D. Increased thermogenesis from shivering

Answer 94

Answer: A

Question 95

A 45 gestational week old neonate is scheduled for repair of a myelomeningocele. Anesthetic considerations include: A. RSI with patient in supine position B. Use of Deep NMB to prevent intraop movement C. Awake intubation in the lateral position D. Use of radiant warmers to prevent heat loss from the myelomeningocele.

Answer 95

Answer: C Toggle Masks Extra 1 Awake intubation in the lateral position is performed to avoid pressure on the meningocele sac. Long-acting muscle relaxants are avoided, allowing the surgeon to use nerve stimulators to identify functional neural elements. Although hypothermia is a frequent complication, care must be taken to prevent drying or thermal injury to the exposed neural tissue by the use of radiant heat lamps.

Question 96

Congenital Heart diseases associated with cyanosis include: A. Eisenmenger's syndrome B. VSD C. PDA D. Coarctation of the Aorta

Answer 96

Answer: A Patients with long-standing left-to-right intracardiac shunting may eventually develop increased pulmonary vascular resistance. When that resistance exceeds the systemic vascular resistance a reversal of the shunting can occur. These patients are said to have Eisenmenger's syndrome.

Question 97

Following the use of epidural morphine for postoperative analgesia after C/s, several studies have reported increased incidence of: A. Abdominal pain B. Recurrent herpes simplex labials infection C. Septicemia D. Thrombocytopenia

Answer 97

Answer B An increased incidence (3.5 - 30%) of recurrent herpes simplex labialis infection had been reported 2 - 5 days following epidural morphine.

Question 98

In the flow-volume loops below, normal is represented by B. The loop that best describes the maternal respiratory pattern during the third trimester is: A B C D

Answer 98

Answer: B Flow-volume loops are unaffected by pregnancy and airway resistance decreases by about 35%.