OB/Gyn packrat Flashcards
(139 cards)
1
Q
On examination of a pregnant patient the physician assistant notes a bluish or purplish discoloration of the vagina and cervix. This is called Answers A. Hegar's sign. B. McDonald's sign. C. Cullen's sign D. Chadwick's sign
A
(c) D. Chadwick’s sign is a bluish or purplish discoloration of the vagina and cervix.
2
Q
On examination of a pregnant patient the physician assistant notes the fundal height is at the level of the umbilicus. This corresponds to what gestational age? Answers A. 16 weeks B. 20 weeks C. 24 weeks D. 28 weeks
A
(c) B. At 20-22 weeks the fundal height is typically at the level of the umbilicus.
3
Q
A 25 year-old female presents with vulvar pruritus and a thick, white vaginal discharge. Which of the following tests will be most helpful in making the correct diagnosis? Answers A. KOH prep B. Gram stain C. Tzanck smear D. FTA-ABS
A
(c) A. KOH prep is used to assist in the diagnosis of vaginal candidiasis, which presents with vulvar pruritus and white curd like, cheesy vaginal discharge.
4
Q
A 25 year-old presents with pelvic pain and uterine bleeding. Her Beta-HCG was 1200 mIU/L six days ago. Her current Beta-HCG is 1600 mIU/L. What is the next best test in the evaluation of this patient? Answers A. Laparoscopy B. Culdocentesis C. Dilation and curettage D. Transvaginal ultrasound
A
(c) D. Transvaginal ultrasound is the best test to separate ectopic from intrauterine pregnancy.
5
Q
A 30 year-old presents with persistent vaginal discharge and vulvar pruritus. The discharge is profuse, frothy, greenish, and foul smelling. pH of the vagina is 6.0. Which of the following is the most likely diagnosis? Answers A. Vulvovaginal candidiasis B. Bacterial vaginosis C. Trichomoniasis D. Atrophic vaginitis
A
(c) C. Trichomoniasis presents with vulvar pruritus and a profuse, frothy, greenish, foul-smelling vaginal discharge with a pH usually exceeding 5.0.
6
Q
A 30-week pregnant patient presents with sudden onset of profuse, painless vaginal bleeding. Which of the following is the most likely diagnosis?
Answers
A. Abruptio placentae
B. Uterine rupture
C. Placenta previa
D. Disseminated intravascular coagulation
A
(c) C. Placenta previa presents with sudden, painless, profuse bleeding in the third trimester.
7
Q
Which of the following prenatal vitamins has been shown to decrease the risk of neural tube defects? Answers A. Riboflavin B. Niacin C. Thiamine D. Folic acid
A
(c) D. Folic acid given daily has been shown to effectively reduce the risk of neural tube defects. It should be started 1-3 months prior to pregnancy.
8
Q
According to the United States Preventive Services Task Force, screening mammography for females without risk factors should be started at what age? Answers A. 35 B. 40 C. 45 D. 50
A
(c) B. The United States Preventive Services Task Force recommends that women should consider screening mammography at age 40 in order to decrease morbidity and mortality from the disease.
9
Q
A 35 year-old female presents with a solitary breast mass. Fine needle aspiration reveals bloody fluid with no malignant cells. What is the next best step in the care of this patient? Answers A. Monthly follow-up B. Excisional biopsy C. Hormone therapy D. Repeat fine needle aspiration
A
(c) B. Excisional biopsy is the next step in cases of bloody fluid, residual mass or thickening.
10
Q
What is the primary treatment for an infected Bartholin's duct cyst? Answers A. Acyclovir B. Azithromycin C. Warm compresses D. Incision and drainage
A
(c) D. Incision and drainage is the treatment of choice for a Bartholin duct cyst.
11
Q
A female patient presents with a vaginal discharge that has a fishy odor. On wet mount examination of the discharge a few white blood cells and many stippled epithelial cells are noted. Which of the following is the treatment of choice for this patient? Answers A. Nonoxynol-9 B. Ceftriaxone C. Metronidazole D. Clotrimazole
A
(c) C. Metronidazole is the treatment of choice for bacterial vaginosis. Bacterial vaginosis presents with a vaginal discharge with a fishy odor and clue cells on wet mount exam.
12
Q
A 36-week pregnant patient presents to the ED with hypertension. Physical examination reveals 2+/4+ edema in the lower extremities with hyperreflexia and clonus bilaterally. A urinalysis reveals 3+ protein. Which of the following is the best treatment option for this patient? Answers A. Magnesium sulfate B. Nifedipine (Procardia) C. Diazepam (Valium) D. Captopril (Capoten)
A
(c) A. Magnesium sulfate is indicated in this patient with preeclampsia to reduce the risk of seizures.
13
Q
A patient presents with infertility due to chronic anovulation. Laboratory testing reveals a normal follicle stimulating hormone, estradiol, and prolactin levels. The patient's progestin challenge test was positive. Which of the following is the drug of choice for the treatment of infertility in this patient? Answers A. Dehydroepiandrosterone sulfate B. Clomiphene citrate C. Bromocriptine D. Human menopausal gonadotropin
A
(c) B. Clomiphene citrate is the first drug of choice in patients with infertility due to anovulation with normal hormone levels.
14
Q
Which of the following autosomal disorders results from the chromosomal abnormality of trisomy 21? Answers A. Edward's syndrome B. Down's syndrome C. Wolf's syndrome D. Cri du chat syndrome
A
(c) B. Down’s syndrome is due to trisomy 21
15
Q
Human papilloma virus has been strongly associated with the development of which of the following? Answers A. Cervical carcinoma B. Ovarian carcinoma C. Pelvic inflammatory disease D. Vaginitis
A
(c) A. Human papilloma virus (types 16, 18, and 31) has been linked to the development of cervical carcinoma.
16
Q
A 28 year-old female presents with lower abdominal pain and vaginal discharge. On examination the patient
is toxic appearing and her temperature is 39°C. Pelvic examination reveals cervical motion tenderness. What is the next best step in the evaluation of this patient?
A. Abdominal x-ray
B. Endocervical culture
C. Laparoscopy
D. Hysterosalpingogram
A
(c) B. Endocervical culture would be helpful in the diagnosis of pelvic infection.
17
Q
A 16 year-old female G1P0Ab0 is 30 weeks pregnant. Her last two monthly prenatal exams have shown a trace to 1 plus proteinuria. The patient denies any previous history of hypertension, seizures, headache, visual disturbances or spotting. On examination, blood pressure is 150/98. The fundal height is 32 cm, the uterus is soft and nontender and fetal heart tones are 160 bpm. DTRs are 4 plus out of 4 plus in the upper and lower extremities, and there is moderate pedal edema bilaterally. The skin examination is unremarkable. Based upon these findings what is the most likely diagnosis?
A. Eclampsia
B. Pre-eclampsia
C. Gestational hypertension D. HELLP Syndrome
A
(c) B. Pre-eclampsia is the hypertension associated with proteinuria. This occurs in greater frequency in nulliparous, adolescent and black women.
18
Q
A 34 year-old female G2P1Ab0 at 36 weeks gestation presents to the clinic with a complaint of a sudden gush of fluid from the vagina 18 hours ago. The patient denies any blood in the discharge but describes the fluid as watery. Examination reveals that there is a collection of fluid in the posterior fornix, the Nitrazine test is blue as well as the fluid giving a fern-like crystallization pattern on a slide. Given these findings what is the appropriate clinical intervention? A. Observation B. Induce labor C. Antibiotics D. Corticosteroids
A
(c) B. Since the patient is 36 weeks gestation and it has been greater than 12 hours since the leakage of fluid, labor should be induced to minimize infection.
19
Q
In the treatment of endometriosis, which of the following medications has a side effect profile that includes loss of bone mineral density, vasomotor symptoms, vaginal dryness and mood changes? A. Oral contraceptives B. Dantrolene (Danazol) C. Leuprolide (Lupron) D. Progestational agents
A
(c) C. Leuprolide is a gonadotropin releasing hormone analogue that results in suppression of gonadotropic secretion. This suppression leads to a hypoestrogenic state which contributes to these side effects.
20
Q
At the time of ovulation in a normal menstrual cycle, there is a peak in the serum concentration of A. luteinizing hormone. B. prostaglandins C. progesterone. D. prolactin.
A
(c) A. Luteinizing hormone is responsible for ovulation and, therefore, peaks at that time.
21
Q
A 32 year-old female G5P4Ab0 at 35 weeks gestation presents to the clinic with sudden painless, profuse vaginal bleeding. The patient states that during the first and second trimesters she had spotting but nothing like this episode. On examination the fetus appears in transverse lie and the uterus is soft, relaxed and nontender. The fetus does not appear in distress. Maternal vital signs are normal. What is the most likely diagnosis? A. Placenta previa B. Placenta abruptio C. Active labor D. Uterine rupture
A
(c) A. Patients who present with placenta previa will have spotting during the first and second trimesters along with a presentation of sudden, painless, profuse bleeding in the third trimester. The uterus usually remains soft and relaxed and nontender as opposed to placenta abruptio, active labor and uterine rupture.
22
Q
Which of the following immunoglobulins crosses the placenta? A. IgM B. IgG C. IgA D. IgD
A
(c) B. IgG, the smallest immunoglobulin, is the only immunoglobulin able to freely pass the placenta, therefore fetal and maternal levels are equal.
23
Q
A postmenopausal patient is diagnosed with rade I breast cancer. The tumor is 0.7 cm in size, estrogen- receptor positive, and axillary nodes are negative. After undergoing a lumpectomy, which of the following adjuvant therapy is indicated for this patient? A. Chemotherapy B. Tamoxifen (Nolvadex) C. Ovarian ablation D. Bisphosphonate therapy
A
(c) B. Tamoxifen is the adjuvant therapy of choice in post menopausal estrogen receptor positive axillary node negative breast cancer.
24
Q
A 29 year-old female G1P1Ab0 presents to the office with a one-month history of amenorrhea and a positive home pregnancy test. Her LNMP was April 4. Using Nägele’s rule what is her EDC? A. January 1 B. January 7 C. January 11 D. January 18
A
(c) C. Nägele’s rule is LMP minus 3 months plus 7 days. April 4 minus 3 months equals January 4 plus 7 days equals January 11.
25
When interpreting a cervical mucus fern test for ovulation, the Physician Assistant finds a fern frond pattern. Which of the following is consistent with this finding?
A. An estrogenic effect without the influence of progesterone indicating no ovulation
B. An estrogenic effect with the influence of progesterone indicating no ovulation
C. An estrogenic effect without the influence of progesterone indicating ovulation
D. An estrogenic effect with the influence of progesterone indicating ovulation
(c) A. When cervical mucus is spread out on a slide the estrogen causes the mucus to develop a fern frond pattern. Progesterone makes the mucus thick and inhibits the fern frond pattern from developing. Absence of the fern frond pattern indicates that ovulation has occurred.
26
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A 29 year-old female G4P2Ab1 at 20 weeks gestation complains of nausea and vomiting with tenderness in the RUQ. Vital signs reveal the patient to be febrile. On physical examination, the abdominal examination reveals positive bowel sounds in all quadrants with a positive Murphy's sign. Fundus can be palpated at the level of the umbilicus. The skin is warm and dry with slight tenting. Oral mucosa is dry as well. What is the most likely diagnosis?
A. Peptic ulcer disease
B. Hyperemesis gravidarum
C. Cholecystitis
D. Viral gastroenteritis
```
(c) C. Gallbladder disease represents one of the most common medical and surgical conditions seen during pregnancy. This is thought to be due to a decrease in gallbladder contractility and lithogenicity of the bile. There is an increased risk in multiparous women.
27
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What is the drug of choice for reversing magnesium sulfate toxicity in the management of premature labor?
A. Calcium gluconate
B. Potassium chloride
C. Naloxone (Narcan)
D. Oxytocin (Pitocin)
```
(c) A. Calcium gluconate is the drug used to reverse magnesium sulfate toxicity.
28
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When assessing for cervical effacement, the Physician Assistant determines that the cervical os is non- distinguishable from the vagina. What is the percentage of effacement?
A. 25
B. 50
C. 75
D. 100
```
c) D. Cervical effacement or thinning is a determination of how much length is left on the cervix. If the cervix is not able to be distinguished from vaginal tissue then the cervix is fully dilated and is completely effaced.
29
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When starting a patient on oral contraceptives, she should be advised to use an additional form of contraception for how long in order to prevent inadvertent pregnancy?
A. 1 week
B. 2 weeks
C. 3 weeks
D. 4 weeks
```
(c) D. Based upon a 28-day cycle, a good practice to recommend is to use an additional form of contraception during the first cycle to maximize efficacy.
30
```
A 28 year-old female with known polycystic ovarian syndrome (PCOS) is seen because of hirsuitism. She does not want to become pregnant at this time. Which of the following is the most appropriate therapy?
A. oral contraceptives
B. Testosterone
C. Clomiphene citrate (Clomid)
D. Metformin (Glucophage)
```
(c) A. Oral contraceptives work to lower the production of steroidogenesis (androgens) by the ovary by inhibiting the secretion of LH. Another important factor for this patient is her desire to not become pregnant.
31
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A 26 year-old female G1P0Ab0 appears to be in the second stage of labor. Vaginal examination reveals the fetal head to be at the level of the maternal ischial spines. What station is this patient at?
A. 0
B. Plus 1
C. Plus 2
D. Minus 1
```
(c) A. Assessment of the fetal head in relation to the ischial spines is known as station. When the fetal head is at the level of the maternal ischial spines it is designated as 0 station. Positive stations are below the maternal ischial spines while negative stations are above the ischial spines.
32
```
Which of the following laboratory markers are helpful in establishing the diagnosis of ovarian cancer in a 55 year-old post-menopausal women?
A. Ca-125
B. CEA
C. LDH
D. AFP
```
(c) A. Ca-125 is one of the best tumor markers in epithelial ovarian cancer.
33
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A 24 year-old sexually active female patient is seen for the first time in the office for a complete history and physical examination. During the history, you find that the patient smokes 2 packs per day and has been sexually active since age 14 with multiple partners without the use of barrier protection. Given this information, what is the patient most at risk for developing?
A. Cervical carcinoma
B. Ovarian carcinoma
C. Uterine carcinoma
D. Vulvar carcinoma
```
(c) A. Human papilloma virus (HPV) is a prime etiologic factor of developing cervical intraepithelial neoplasia (CIN) and cervical cancer. Cigarette smoking and HPV is associated with a two-to-four fold increase in the relative risk for developing cervical cancer.
34
```
On examination of a pregnant patient the physician assistant notes a bluish or purplish discoloration of the vagina and cervix. This is called
A. Hegar's sign.
B. McDonald's sign.
C. Cullen's sign
D. Chadwick's sign
```
(c) D. Chadwick's sign is a bluish or purplish discoloration of the vagina and cervix.
35
Progesterone influence on the breast tissue prior to menstruation causes
A. proliferation of the mammary ducts.
B. growth of the lobules and alveoli.
C. proliferation of Cooper's ligaments.
D. increase in the number of glands of Montgomery.
(c) B. Growth of the lobules and alveoli is under the influence of progesterone. Prior to menses, the breast swelling that women notice is a result of the progesterone which is secreted from the corpus luteum. During menses, the swelling subsides.
36
```
A 40 year-old female presents with a 1.5 cm well-circumscribed mass noted on mammography in the right upper, outer quadrant. Which of the following procedures is most appropriate and should be done next?
A. Fine needle aspiration
B. BRCA 1 and BRCA 2 genetic testing
C. Serum CA-125
D. Radiation therapy
```
(c) A. Fine needle aspiration is fairly accurate, easily performed, and has minimal morbidity.
37
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On examination of a pregnant patient the physician assistant notes the fundal height is at the level of the umbilicus. This corresponds to what gestational age?
A. 16 weeks
B. 20 weeks
C. 24 weeks
D. 28 weeks
```
(c) B. At 20-22 weeks, the fundal height is typically at the level of the umbilicus.
38
```
Pharmacologic treatment of a patient with gestational diabetes should consist of which of the following?
A.Oral hypoglycemic agents
B. Regular insulin
C. Oral corticosteroids
D. Glucagon
```
(c) B. Regular insulin is the drug of choice as this will maintain the mother's blood sugar but not cross the placenta.
39
```
What is the initial treatment of choice for hyperthyroidism in a 10-week pregnant patient?
A. No treatment is necessary.
B. Propylthiouracil (PTU)
C. Radioiodine treatment
D. Subtotal thyroidectomy
```
(c) B. This is the initial treatment of choice.
40
```
Treatment of the patient with Pediculosis pubis consists of which of the following?
A. Permethrin (Nix) cream
B. Clotrimazole (Gyne-Lotrimin)
C. Podofilox (Condylox) solution
D. Selenium sulfide (Selsun) suspension
```
(c) A. Permethrin 1% cream/shampoo is used to kill the louse and remove the eggs from the hair shafts.
41
Patient education for a 23 year-old using oral contraceptives should include which of the following?
A. Rifampin may decrease the effectiveness of the oral contraceptives.
B. Acetaminophen may decrease the effectiveness of the oral contraceptives.
C. Oral contraceptives may provide some protection from coronary artery disease.
D. Changing to the "minipill" (progestin only) will inhibit ovulation more consistently than combination oral
contraceptives.
(c) A. Rifampin may interfere with the efficacy of the oral contraceptives.
42
If a woman has a normal 28-day menstrual cycle what tissue and hormonal phase occurs during the last 14 days?
A. Proliferative follicular phase under the influence of estrogen.
B. Secretory luteal phase under the influence of estrogen and progesterone.
C. Proliferative follicular phase under the influence of estrogen and progesterone.
D. Secretory luteal phase under the influence of estrogen.
(c) B. The endometrial changes seen in the latter half of the cycle are under the influence of both estrogen and
progesterone from the corpus luteum. During this phase, the endometrium becomes more vascularized and
slightly edematous.
43
```
Which of the following clinical manifestations is common in candidal vulvovaginitis?
A. Extreme vulvar irritation
B. Firm, painless ulcer
C. Tender lymphadenopathy
D. Purulent discharge
```
(c) A. Candida infection presents with pruritus, vulvovaginal erythema, and white, cheese-like (curd) discharge that may be malodorous.
44
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A 35 year-old female presents with multiple ulcerative lesions on her labia and perineum. A Tzanck preparation of one of the lesions reveals multinucleated giant cells. Which of the following is the most likely diagnosis?
A. Herpes Simplex Virus (HSV)
B. Molluscum Contagiosum Virus (MCV)
C. Human Papilloma Virus (HPV)
D. Syphilis
```
(c) A. The presentation seen on the Tzanck preparation is characteristic of HSV.
45
It is determined that a woman has a nonexistent rubella titer level during her first trimester of pregnancy. When should she receive the rubella vaccine?
A. During the first trimester of pregnancy
B. During the second trimester of pregnancy
C. During the third trimester of pregnancy
D. After delivery of the infant
(c) D. The patient should not receive the rubella vaccine during the course of her pregnancy as the possibility of
transmission of the rubella virus does exist. During the time that the patient is without protective titer she should avoid anyone with active rubella infection. The proper time to receive the vaccine is after delivery of the infant.
46
A 72 year-old female presents with vulvular pruritus for the last nine months, which has progressively worsened over the last two months. She states that she went through menopause at age 54 and has been on estrogen and progesterone therapy since that time. Physical examination reveals red lesions with white plaques on the vulva. What should the next course of management include?
A. Refer to a gynecologist for biopsy.
B. Refer to a dermatologist for antifungal therapy.
C. Treat with a topical steroid.
D. Treat with estrogen cream.
(c) A. Vulvular squamous cell hyperplasia causes thickening and hyperkeratosis of the vulva. The lesions are red and moist and cause intense pruritus over time the area becomes thickened and a white plaque may develop. Biopsy must be done to evaluate for intraepithelial neoplasm or invasive tumor.
47
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A 30 year-old female presents to the emergency department with a syncopal episode. She has a history of irregular menstrual cycles and infertility. She has scanty, persistent vaginal bleeding and sharp pelvic pain. A left adnexal mass is palpated. The most likely diagnosis is
A. placenta abruptio.
B. ectopic pregnancy.
C. pelvic inflammatory disease.
D. ruptured ovarian cyst.
```
(c) B. Infertility increases the risk of developing ectopic pregnancy. The onset of vaginal bleeding, pelvic pain, and formation of an adnexal mass makes this the most likely diagnosis.
48
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To relieve dependent edema in a pregnant patient, which of the following should be instituted as treatment?
A. Limit fluid intake.
B. Elevate the legs.
C. Prescribe thiazide diuretics.
D. Strict avoidance of sodium.
```
(c) B. Dependent edema is a common and rarely serious complication of pregnancy due to impedance of venous
return. Leg elevation improves circulation.
49
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A 33 year-old female presents for follow-up of her Pap smear that showed cervical dysplasia. Which of the following is the most appropriate diagnostic procedure?
A. Cone biopsy
B. Aspiration needle biopsy
C. Dilation and curettage
D. Colposcopy-directed biopsy
```
(c) D. A colposcopy-directed biopsy is the first diagnostic evaluation indicated for cervical dysplasia.
50
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A decrease in the fetal heart rate (FHR) occurring late during contractions is noted. The FHR returns to the baseline slowly after the uterine contraction. The physician assistant should be alerted to the possibility of
A. pelvic dystocia.
B. precipitous labor.
C. fetal head compression.
D. placental insufficiency.
```
(c) D. Placental insufficiency is the probable cause of fetal distress resulting in late decelerations.
51
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A 47 year-old female presents to the clinic with complaints of prolonged, heavy menses that have been getting progressively worse for 3 years. She denies any pain. On physical examination, enlargement of the uterus with multiple smooth, spherical, firm masses is noted. A CBC is consistent with a mild anemia. Which of the following is the most likely diagnosis?
A. Leiomyoma
B. Adenomyosis
C. Endometriosis
D. Endometrial polyps
```
(c) A. Abnormal uterine bleeding and irregular enlargement of the uterus are most consistent with leiomyoma. Pain is rarely present unless vascular compromise occurs.
52
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A 28 year-old woman is complaining of heavy uterine bleeding and pelvic pressure that has progressively worsened over the past year. Evaluation reveals multiple moderate-sized uterine fibroids. The patient desires to have more children. The most appropriate definitive treatment is
A. Myomectomy.
B. Hysterectomy.
C. GnRH agonists.
D. Oral progesterone.
```
(c) A. Myomectomy is the definitive treatment of choice for moderate-sized uterine fibroids in young women who desire to maintain reproductive capability.
53
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A 22 year-old G0P0 asymptomatic female is seen for her yearly gynecologic examination. She denies performing self-breast exams and any family history of breast or gynecologic cancers. On palpation of her left breast, a solitary 1 cm rubbery, firm, well-circumscribed, non-tender breast mass is noted. In review of her records, similar findings were noted on last year's examination. Which of the following is the most likely diagnosis?
A. fibroadenoma
B. breast fat necrosis
C. fibrocystic changes
D. intraductal papilloma
```
(c) A. Fibroadenoma of the breast most commonly is seen in young females. Typical characteristics include a solitary 1-3 cm firm, painless, freely movable mass that does not change with the menstrual cycle and are slow growing. Most are found as an incidental finding on physical examination or during self-breast examination.
54
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Which of the following is the most common underlying cause of early postpartum hemorrhage?
A. uterine atony
B. genital tract trauma
C. coagulation disorders
D. retained placental tissue
```
(c) A. Uterine atony is the most common cause of postpartum hemorrhage. Predisposing factors include any conditions that cause excessive uterine enlargement, abnormal labor or conditions that interfere with uterine contraction.
55
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Which of the following is the earliest and most reliable clinical manifestation of pre-eclampsia?
A. onset of proteinuria
B. elevation of blood pressure
C. excessive weight gain and edema
D. headache and visual distrubances
```
(c) B. Elevated blood pressure is the most important and reliable diagnostic criterion. It is seen early in the course of pre-eclampsia and may occur suddenly.
56
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Which of the following is the most significant factor in the production of menopausal symptoms?
A. decrease in estrogen
B. decrease in testosterone
C. increase in progesterone
D. increase in androstenedione
```
(c) A. A decrease in estrogen is responsible for the majority of menopausal symptoms including, but not limited to, hot flashes, sleep disturbances, genital tract atrophy and mood changes.
57
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Which of the following is associated with meconium-stained amniotic fluid during labor?
A. transition
B. prematurity
C. fast labor
D. fetal distress
```
(c) D. Passage of meconium is associated with fetal distress usually due to asphyxia.
58
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A 29 year-old female presents for routine prenatal visit at 26 weeks gestation. She has no complaints and has completed all the initial routine obstetrical diagnostic tests to date. Her physical examination and all initial diagnostic evaluations are unremarkable. Which of the following is the most appropriate diagnostic test to order at this time?
A. VDRL
B. amniocentesis
C. maternal serum alpha-fetoprotein
D. 1-hour post-Glucola blood glucose
```
(c) D. Glucose screening, usually with a 1-hour Glucola, is routinely performed between 24-28 weeks gestation to evaluate for glucose intolerance.
59
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Which of the following is a major risk factor for an ectopic pregnancy?
A. alcohol intake
B. young maternal age
C. history of salpingitis
D. low dose oral contraceptive use
```
(c) C. A previous history of salpingitis is a major risk factor for ectopic pregnancy since damage to the fallopian tube prevents the fertilized ovum from reaching the uterus prior to implantation.
60
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A 24 year-old female presents with complaints of dysuria associated with fever, malaise, myalgias and headache for the past 3 days. Today she noticed some lesions on her genitalia. Physical examination reveals the presence of multiple clear vesicles and erythematous ulcers with tender bilateral inguinal adenopathy. Which of the following is the most appropriate treatment for this patient?
A. valacyclovir (Valtrex)
B. metronidazole (Flagyl)
C. ceftriaxone (Rocephin)
D. benzathine penicillin G (Bicillin)
```
(c) A. This patient most likely has herpes genitalis which may be treated with oral antivirals, such as valacyclovir, that will reduce the duration of viral shedding and shorten the duration of symptoms.
61
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A 27 year-old G1P0 female presents complaining of painless spotting since this morning. She is known to be 12 weeks pregnant. Pelvic examination reveals the presence of blood within the vagina with a closed cervical os. The uterus is consistent with a 10-12 week gestation and nontender to palpation. Which of the following is the most likely diagnosis?
A. inevitable abortion
B. threatened abortion
C. incomplete abortion
D. complete abortion
```
(c) B. Vaginal bleeding that occurs prior to the 20th week of gestation is classified as a threatened abortion. Pain is usually not a major feature and vaginal examination usually reveals a closed cervical os.
62
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A 65 year-old postmenopausal female presents with complaints of new onset of vaginal bleeding. She relates a history of two episodes of vaginal bleeding during the past month, each lasting about four days. Which of the following diagnostic evaluations is the most reliable to evaluate the suspected diagnosis?
A. Pap smear
B. endometrial biopsy
C. serum prolactin level
D. serum FSH and LH levels
```
(c) B. Postmenopausal bleeding is a primary complaint in patients with endometrial cancer. The only reliable method of diagnosis is by endometrial biopsy.
63
A 32 year-old female G4P4 with a history of multiple sexual partners is seen in follow-up for recent findings of high grade squamous intraepithelial lesions (HSIL) on a Pap smear. Which of the following is the most appropriate next step?
A. HPV DNA testing
B. pelvic ultrasound
C. repeat Pap smear in 4-6 months
D. colposcopy with endocervical curettage
(c) D. Colposcopy with endocervical curettage and directed biopsy of suspicious lesions is the appropriate evaluation of a high grade squamous intraepithelial lesions (HSIL) Pap smear result.
64
Which of the following is a contraindication to prescribing oral hormonal contraceptives?
A. history of iron deficiency anemia
B. history of dysmenorrhea since age 15
C. positive family history of ovarian cancer
D. history of smoking in a patient older than age 35
(c) D. A history of smoking in a patient older than age 35 is considered one of the absolute contraindications to prescribing oral hormonal contraceptives due to the increased risk of thromboembolic events.
65
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Which of the following is the most common presenting clinical manifestation of breast cancer?
A. breast tenderness
B. nipple discharge
C. nipple retraction
D. breast mass
```
(c) D. A breast mass is the most common presenting clinical manifestation of breast cancer found by the patient or health care provider.
66
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An increased incidence of breast cancer is associated with
A. nulliparity.
B. late menarche.
C. trauma to the breast.
D. early natural menopause.
```
(c) A. Nulliparous women have a 1.5 times higher incidence of breast cancer than multiparous women.
67
An 18 year-old female presents with 2-day duration of dysuria, vulvovaginal pruritis, and a frothy clear to white discharge. Which of the following results would be expected?
A. clue cells on normal saline preparation
B. hyphae and budding yeast on a KOH preparation
C. intracellular gram negative diplococci on Gram stain
D. mobile flagellated protozoa on a normal saline preparation
(c) D. Trichomonas presents with a frothy discharge, irritative symptoms of pruritus, dysuria, and frequency, and the flagellated protozoa are demonstrated on a saline preparation.
68
In which of the following maternal-fetal blood type pairings should the mother receive Rho-GAM?
A. A positive mother, O negative infant
B. A negative mother, O negative infant
C. AB positive mother, spontaneous abortion
D. AB negative mother, spontaneous abortion
(c) D. Rho-GAM is indicated for an unsensitized Rh-negative patient who has had a spontaneous or induced abortion, ectopic pregnancy, or at the time of amniocentesis. It is also indicated at 28 weeks gestation and within 72 hours of delivery of an Rh-positive infant.
69
```
A 13 year-old female presents with a six month history of lower mid-abdominal pain that is spasmodic in nature and radiates to the inner thighs. The pain usually starts within a few hours of the onset of menses and lasts about 2 days. The patient's menarche began 2 years ago. She denies any sexual activity. Physical examination, including pelvic, is unremarkable. Which of the following is the most likely diagnosis?
A. ovarian cyst
B. endometriosis
C. primary dysmenorrhea
D. premenstrual syndrome
```
(c) C. This patient most likely has primary dysmenorrhea supported by onset of pain within 1-2 years after onset of menarche and characteristic symptoms of low, mid-abdominal, spasmodic cramping pain that radiates to the back or inner thighs beginning on the first or second day of menstruation. Pelvic examination fails to reveal any pathological findings.
70
```
A 26 year-old monogamous female presents with cyclic pelvic pain that has been increasing over the last 6 months. She complains of significant dysmenorrhea and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis?
A. Ovarian cancer
B. Endometriosis
C. Functional ovarian cyst
D. Pelvic inflammatory disease
```
(c) B. With endometriosis, the uterus is often fixed and retroflexed in the pelvis. The palpable mass is an endometrioma or "chocolate cyst". The patient with endometriosis also often has dysmenorrhea, dyspareunia, and dyschezia.
71
What is the recommended method for screening pregnant women for gestational diabetes?
A. Fasting blood sugar and 2 hour post prandial
B. 50 gram glucose load followed by a blood sugar in 1 hour
C. 75 gram glucose load followed by a blood sugar in 2 hours
D. 100 gram glucose load followed by a blood sugar at 1 hour, 2 hours, and 3 hours
(c) B. One hour Glucola is the screening test for gestational diabetes. It is a 50 gram glucose load, with a serum glucose obtained 1 hour after the dose. Normal value is less than 140 mg/dL.
72
```
What is the treatment of magnesium sulfate toxicity?
A. Nifedipine
B. Terbutaline
C. Potassium carbonate
D. Calcium gluconate
```
(c) D. 10% calcium gluconate is used to treat magnesium sulfate toxicity.
73
A 52 year-old obese patient with persistent heavy menses undergoes an endometrial biopsy and is diagnosed with atypical adenomatous hyperplasia. What is the next step in the management of this patient?
A. Total abdominal hysterectomy
B. Observation and endometrial biopsy in 3 months
C. Endometrial curettage followed by progesterone daily
D. Oral progesterone days 16-25 of the month for 6 months and repeat biopsy
(c) A. Atypical adenomatous hyperplasia contains cellular atypia and mitotic figures in addition to glandular crowding and complexity. This has a 20-30% risk of progression to endometrial cancer and the recommendation is hysterectomy.
74
```
A 23 year-old female is in active labor and has progressed from 3 cm to 6 cm in the last six hours. Fetal monitoring demonstrates mild repetitive late decelerations. Which of the following is the most likely cause of this finding?
A. Fetal hypoxia
B. Head compression
C. Cord compression
D. Uteroplacental insufficiency
```
(c) D. Late decelerations are from uteroplacental insufficiency. The decelerations have a smooth, gradual symmetrical decrease in FHR beginning at or after the peak of the contraction.
75
```
A 16 year-old G0P0 patient presents complaining of lower pelvic pain that alternates from right to left side of her pelvis. She states that it is related to her cycle and occurs most commonly midcycle. She denies sexual activity. She reports that she has taken ibuprofen at the time of the discomfort with some relief. Her pelvic examination is unremarkable. Which of the following is the most likely diagnosis?
A. Endometriosis
B. Mittelschmerz
C. Functional ovarian cyst
D. Pelvic inflammatory disease
```
(c) B. Women may experience pain at the time of ovulation, may alternate side to side.
76
A patient with preterm labor may be given corticosteroids to
A. decrease uterine activity.
B. prevent chorioamnionitis.
C. enhance fetal lung maturity.
D. prevent the development of gestational diabetes.
(c) C. Corticosteroids may be given from 24-34 weeks in patients with preterm labor or who have pregnancy complications which may cause premature birth. The corticosteroids enhance pulmonary maturity.
77
```
An 18 year-old female comes to the clinic with the complaint of increased vaginal discharge and vaginal odor. She also complains of urinary frequency. On physical examination there is evidence of thin, gray, frothy discharge in the vagina. The cervix appears erythematous and the vaginal pH is 6. Which of the following is the most likely diagnosis?
A. Candida vaginitis
B. Bacterial vaginosis
C. Trichomonas vaginitis
D. Chlamydia trachomatis
```
(c) C. Signs of trichomonas include: thin frothy or bubbly, pale yellow-green to gray adherent vaginal discharge, can have erythema of vulva and vagina, may have petechiae on the cervix, amine odor may be present, may also complain of dysuria and dyspareunia, pH 5 to 6.5 (basic).
78
```
Mastitis associated with breastfeeding is most commonly caused by what bacteria?
A. Listeria monocytogenes
B. Escherichia coli
C. Staphylococcus aureus
D. Streptococcus pyogenes
```
(c) C. The most common pathogen associated with postpartum mastitis is Staphylococcus aureus which arises from the nursing infant's throat and nose.
79
A 40 year-old female presents with a Pap smear abnormality revealing atypical glandular cells (AGUS). What is the most appropriate intervention?
A. HPV DNA testing
B. Colposcopy with endometrial curretage(ECC)
C. Repeat Pap smear in 3 months
D. Colposcopy and endometrial sampling
(c) D. Colposcopy and endometrial sampling are important to perform in patients with AGUS Pap results because glandular cells are associated with squamous and glandular precursor lesions and carcinoma.
80
```
What is the most common cause of secondary amenorrhea?
A. Pregnancy
B. Ovarian failure
C. Imperforate hymen
D. Hypothalamic amenorrhea
```
(c) A. Pregnancy is the most common cause of amenorrhea and is essential to exclude by a serum or urine pregnancy test.
81
Which of the following tests is the most specific for the diagnosis of syphilis?
A. Rapid plasma reagin (RPR)
B. Weil-Felix agglutination test
C. Venereal Disease Research Laboratory (VDRL)
D. Fluorescent treponemal antibody absorption (FTA-ABS)
(c) D. The FTA-ABS and the MTA-TP are specific treponemal tests used for the confirmation of syphilis.
82
```
Maternal blood pressure normally decreases the most during what period of pregnancy?
A. First trimester of pregnancy
B. Second trimester of pregnancy
C. Third trimester of pregnancy
D. During labor and delivery
```
(c) B. Diastolic blood pressure and the mean arterial pressure reach their nadir at 16-20 weeks of gestation.
83
```
A 35 year-old G2P1001 female presents to the office at 11 weeks gestation with vaginal bleeding, mid-lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, bright red blood is seen coming from the cervical os. The cervix is closed. The uterus is 9-11 weeks in size by palpation. Her blood pressure is 120/70 mmHg and her pulse rate is 96. What is the patient's most likely diagnosis?
A. Inevitable abortion
B. Incomplete abortion
C. Threatened abortion
D. Missed abortion
```
(c) C. If bleeding occurs in the first 20 weeks of pregnancy and the cervix is closed, threatened abortion is the diagnosis.
84
```
What should be the initial evaluation of the etiology of infertility in a 25 year-old female who has been trying to conceive for 1 year?
A. Endometrial biopsy
B. Hysterosalpingogram
C. Serum progesterone levels
D. Basal body temperature measurements
```
(c) D. Basal body temperature measurement is an excellent screening test for ovulation, and will help with the timing of coitus.
85
```
On rectovaginal examination of a 72 year-old post-menopausal female a 3 cm by 3 cm right adnexal mass is palpated. The rest of her physical examination is unremarkable. Her last gynecological examination was last year and was unremarkable. Which of the following is the most likely diagnosis?
A. Ovarian cancer
B. Endometrioma
C. Uterine cancer
D. Functional ovarian cyst
```
(c) A. Ovaries should not be palpable in the postmenopausal patient. Consider ovarian cancer until proven otherwise.
86
A 56 year-old female patient comes to the office for evaluation. She complains of dyspareunia and a thin vaginal discharge. On physical examination atrophic vulvar changes are noted associated with vaginal petechiae and a thin clear discharge. What medication is recommended to treat this patient's symptoms?
A. Topical estrogen (Estrace) cream
B. Topical hydrocortisone (Gynecort)
C. Metronidazole (MetroGel) vaginal gel
D. Terconazole (Terazol) vaginal suppository
(c) A. This patient has atrophic vaginitis which is very common in postmenopausal patients. The vagina will appear atrophied, will look pale, and thin and dry in appearance. Best to treat with topical or oral estrogen preparations.
87
```
You are performing a routine gynecological examination on a 49 year-old female. She states that for the last six months her periods have been getting heavier and lasting for seven days duration. She also tells you that she has been experiencing urinary frequency and constipation. Her abdominal exam is unremarkable. On pelvic examination you feel a slightly enlarged uterus and a left adnexal mass that moves with the uterine fundus. Which of the following is the most likely diagnosis?
A. Adenomyosis
B. Uterine fibroids
C. Ovarian neoplasm
D. Diverticular disease in the colon
```
(c) B. Patients with uterine fibroids often have menorrhagia and/ or metrorrhagia. On examination, the uterus will be larger, and irregularly-shaped. If a mass is present and it moves with the uterus, it is suggestive of a fibroid.
88
```
At the time of ovulation in a normal menstrual cycle, there is a peak in the serum concentration of which of the following?
A. Luteinizing hormone
B. Prostaglandin
C. Progesterone
D. Prolactin
```
(c) A. Luteinizing hormone is responsible for ovulation and, therefore, peaks at that time.
89
An 18 year-old G1P0 female presents for her 35 week prenatal visit with complaints of headache, blurred vision and right upper quadrant discomfort. Vital signs show BP of 170/100 mmHg and brisk patellar reflexes. Urinalysis shows 3+ proteinuria. Fetal heart tones are 150. What is your next step in the care of this patient?
A. Admit to hospital and prepare for delivery
B. Admit to hospital with antepartum fetal surveillance and close monitoring of maternal conditions
C. Order bed rest at home with daily fetal movement counts and twice weekly antepartum care
D. Order bed rest at home with administration of prophylactic magnesium sulfate
(c) A. Severe preeclampsia mandates hospitalization. Delivery is indicated if gestational age is 34 weeks or greater.
90
A 30 year-old female presents to the clinic for her 6 week post partum examination. She was diagnosed with gestational diabetes mellitus during her pregnancy and was successfully treated with diet alone. Which of the following patient education statements is most appropriate for this patient?
A. The risk of gestational diabetes occurring in future pregnancies is very low.
B. The risk of developing diabetes in 10-15 years is relatively low.
C. Lifestyle modification, diet & exercise will not prevent her from developing diabetes
D. Glucose testing every 1-3 years is recommended
(c) D. Those with normal glucose should be reassessed every 3 years; those with prediabetes should be assessed annually.
91
```
A 30 year-old female presents to the emergency room having passed out at home 30 minutes prior to arrival. Her last menstrual period was 6 weeks ago and pregnancy test was reported positive 5 days ago. She started having vaginal bleeding last night. Vital signs are BP 70/40 mmHg, P 140 bpm, R 22. She is pale and diaphoretic. The next step in the evaluation of this patient's condition should be which of the following?
A. Abdominal ultrasound
B. Culdocentesis
C. Laparotomy
D. Magnetic resonance imaging
```
(c) C. Laparotomy is indicated with presumptive diagnosis of ectopic pregnancy in an unstable patient.
92
A 32 year-old female complains of severe irritability and emotional lability accompanied by weight gain, breast tenderness, and headache starting mid-cycle each month and abating with the onset of menses. She has tried relaxation therapy, exercise, dietary changes and over the counter pharmacologic interventions with minimal relief of her symptoms. Which of the following prescription medications is the best choice to relieve her symptoms?
A. Alprazolam (Xanax)
B. Fluoxetine (Prozac)
C. Oral contraceptive pill (Ortho-novum 1/35)
D. Spironolactone (Aldactone)
(c) B. SSRI's provide symptom improvement for patients with premenstrual syndrome (PMS).
93
```
During a routine prenatal visit, the fundal height is found to be at the umbilical level. The number of weeks gestation is estimated to be
A. 10 to 12.
B. 16 to 18.
C. 20 to 22.
D. 26 to 28.
```
(c) C. At 20 weeks, fundal height is at the umbilicus.
94
```
A 26 year-old gravida 0 sexually active female presents to the emergency room complaining of colicky pain in her lower abdomen for the past 12 hours. She passed out earlier in the day while trying to have a bowel movement. Her last menstrual period was 6 weeks ago. She has noted vaginal spotting over the last 24 hours. Vital signs show Temp 37 degrees C, BP 96/60mmHg, P 110, R 16, Oxygen Sat. 98%. Abdominal exam is positive for distension and tenderness. Bowel sounds are decreased. Pelvic exam shows cervical motion and adnexal tenderness. Which of the following is the most likely diagnosis?
A. Ectopic pregnancy
B. Appendicitis
C. Crohn's disease
D. Pelvic inflammatory disease
```
(c) A. High suspicion for ectopic pregnancy should be maintained when any possible pregnant woman presents with vaginal bleeding or abdominal pain.
95
```
A 46 year-old G4P4 African American female presents to the clinic complaining of heavy and prolonged menstrual flow over the past 6 months. Gynecological history includes menarche age 12 and LMP 3 weeks prior. Pelvic exam reveals a 14-week size, irregular uterus. Pelvic ultrasound shows the presence of a large intramural fibroid with normal endometrial lining. Which of the following is the most appropriate management for this patient?
A. Oral contraceptive pill
B. Levonorgestrel-releasing IUD
C. Hysterectomy
D. Myomectomy
```
(c) C. Large leiomyomas are the most common indication for hysterectomy in this age group.
96
```
A 29 year-old female G1P1 presents to the office with a one-month history of amenorrhea and a positive home pregnancy test. The first day of her last menstrual period (LMP) was April 4. Using Nägele's rule what is her EDC?
A. January 1
B. January 7
C. January 11
D. January 18
```
(c) C. Nägele's rule is LMP minus 3 months plus 7 days. April 4 minus 3 months equals January 4 plus 7 days equals January 11.
97
```
A 29 year-old female has been diagnosed with infertility due to anovulation. Her provider suggests using a medication that will block the feedback inhibition of estradiol on the hypothalamus and pituitary leading to an increase in FSH. Which of the following medications is the most appropriate for this patient?
A. Leuprolide (Lupron)
B. Clomiphene citrate (Clomid)
C. Medroxyprogesterone acetate (Provera)
D. Metformin (Glucophage)
```
(c) B. Clomiphene citrate is the agent of choice for women younger than 36 years of age who need induction of ovulation
98
```
A 22 year-old G1P0 female presents at 12 weeks gestation with 24 hours of vaginal bleeding. She complains of continued cramping and bleeding requiring pad change every two hours. Vital signs are normal. Vaginal examination shows bleeding with a dilated cervix. Which of the following is the most likely diagnosis?
A. Threatened abortion
B. Inevitable abortion
C. Incomplete abortion
D. Complete abortion
```
(c) B. Abortion is inevitable when cervical effacement, dilatation and rupture of membranes is noted.
99
```
A 46 year-old woman describes her menstrual periods as regular (occurring every 30 days), prolonged, and with a heavy flow. You document this finding as which of the following?
A. Menorrhagia
B. Oligomenorrhea
C. Metrorrhagia
D. Hypomenorrhea
```
(c) A. Menorrhagia describes long and heavy flow menstrual flow.
100
```
A 54 year-old female comes to your office with the complaint of vaginal itching. Her last menstrual period was three years ago. On examination the patient's vulva is smooth and somewhat shiny; her vaginal mucosa is pale and thin with a mild yellowish discharge with a pH of 6.0. The most likely cause of these symptoms is which of the following?
A. Lichen sclerosis
B. Atrophic vaginitis
C. Contact Dermatitis
D. Candidiasis
```
(c) B. Atrophic vaginitis is typically caused by reduced estrogen levels producing intense itching and thin vaginal mucosa with a resultant yellowish discharge that has a pH > 5.5.
101
```
A 25 year-old G2P2 married female presents to the clinic for birth control counseling. Her past history includes deep vein thrombosis with her last pregnancy. She does not want another pregnancy for at least 4 years. The birth control method that would be best for this patient is which of the following?
A. Vaginal ring
B. Transdermal patch
C. Combined oral contraceptive pill
D. Levonorgestrel releasing IUD
```
(c) D. IUD releases potent progestin only; is not a combination contraceptive.
102
```
A 24 year-old sexually active woman presents to the clinic complaining of dysmenorrhea, dyspareunia and backache that occurs premenstrually. Pelvic examination shows pain upon uterine motion and uterosacral nodularity in the posterior vaginal fornix. The definitive diagnosis for this patient requires which of the following?
A. Pelvic ultrasound
B. CT of the abdomen
C. Laparoscopy with biopsy
D. CA-125 test
```
(c) C. Diagnosis of endometriosis must be made by direct visualization. Laparoscopy with biopsy is the most appropriate diagnostic study in this patient.
103
A 56 year-old female presents to the clinic wanting testing for ovarian cancer. Her best friend was just diagnosed with Stage 4 primary cancer of the ovary. She denies family history of breast or ovarian cancer. According to screening guidelines, which of the following do you recommend?
A. BRCA 1-2 gene testing
B. A pelvic ultrasound yearly
C. Continue her yearly women's health examinations
D. CA-125testing
(c) C. The patient is advised to have regular pelvic exams. The limited prevalence of ovarian cancer and the lack of sensitivity and specificity of current available tests have so far prevented the implementation of routine ovarian cancer screening of the general population.
104
```
Which of the following best describes the purpose of intravenous magnesium sulfate in patients with preeclampsia?
A. Prevention of convulsions
B. Prevention of HELLP syndrome
C. Lowering of blood pressure
D. Reversal of proteinuria
```
(c) A. Magnesium sulfate is used to prevent and treat eclamptic seizures. Magnesium sulfate is not sufficient to treat hypertension, therefore antihypertensives must be added. Magnesium sulfate is excreted solely from the kidneys and urine output must be preserved to prevent accumulation of the drug. Magnesium sulfate does nothing to prevent HELLP syndrome.
105
```
A 25 year-old female presents for a routine gynecological examination. You palpate a 2 cm breast mass in her right breast. Her menstrual period was last week. She has no family history of breast cancer. What is the modality of choice to further evaluate her breast mass?
A. Magnetic resonance imaging (MRI)
B. Excisional biopsy
C. Ultrasound
D. Mammography
```
(c) C. In a 25 year-old an ultrasound is the best choice because of the density of the breast tissue in young women
106
```
A 26 year-old woman requests screening after her boyfriend was treated for a sexually transmitted infection recently. On examination you find a painless vulvar ulcer. Which of the following is the most likely diagnosis?
A. Herpes
B. Syphilis
C. Chancroid
D. Granuloma inguinale
```
(c) B. The primary lesion of syphilis presents as a painless ulcer or chancre. Secondary syphilis presents with a skin rash lymphadenopathy and mucocutaneous lesions.
107
A 16 year-old nulliparous acutely ill female presents with bilateral lower abdominal pain. She has a temperature of 100.4 degrees F and on examination has a tender, enlarged left adnexa. Cervical culture is positive for Chlamydia. Ultrasound reveals a complex tubular structure in the left adnexal area. What is the recommended treatment?
A. Outpatient treatment with IM ceftriaxone and oral doxycycline
B. Oral doxycycline
C. IM procaine penicillin
D. Hospitalization with parenteral doxycycline and cefoxitin
(c) D. This patient has pelvic inflammatory disease and most likely a tubo-ovarian abscess. It is recommended that the patient be hospitalized and treated with high-dose IV antibiotic therapy. For patients with tubo-ovarian abscesses, surgical drainage is often necessary.
108
Dysmenorrhea would most likely occur in which of the following patients?
A. A young teenager who just started having her menses
B. A woman on birth control pills
C. A marathon runner with one menses per year
D. A 35 year-old woman with regular cycles
(c) D. Women with regular menstrual cycles are most likely to have dysmenorrhea. Dysmenorrhea is caused by a excess of prostaglandin F 2 alpha. Prostaglandin production increases under the influence of progesterone, reaching a peak at, or soon after, the start of menstruation.
109
```
A 25 year-old female, G2 P1001, presents to your office at 11-weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, blood is noted at the dilated cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8-9 weeks gestation. No other abnormalities are found. Which of the following is the most likely diagnosis?
A. Threatened abortion
B. Inevitable abortion
C. Incomplete abortion
D. Complete abortion
```
(c) B. Inevitable abortion is the gross rupture of membranes in the presence of cervical dilation.
110
Which of the following is recommended to reduce the risk for perinatal transmission of HIV in a patient with a viral load of >1000 copies/mL?
A. Vaginal delivery with female condom
B. Episiotomy to shorten second stage of labor
C. Use of forceps or vacuum extractor to shorten second stage of labor
D. Cesarean section prior to onset of labor and rupture of membranes
(c) D. Cesarean section performed prior to the onset of labor and rupture of membranes significantly reduces the risk of perinatal HIV transmission. Planned cesarean section delivery at 38 weeks of gestation to prevent perinatal transmission of HIV is recommended in women with a viral load of >1000 copies/mL.
111
On physical examination of a pregnant patient, which can be considered a normal finding?
A. Increased second heart sound split with inspiration
B. Diastolic murmur
C. Facial edema
D. Hyperreflexia
(c) A. Increased second heart sound split with inspiration is common in pregnancy due to the increased blood flow across the aortic and pulmonic valves.
112
When is the recommendation for the next Pap smear in a 36 year-old patient with a history of 3 consecutive negative annual Pap smears and no history of cervical dysplasia?
A. Yearly Pap smears
B. Pap smear in 4 years
C. Papsmearin3years
D. Patient does not need any further Pap smears
(c) C. Women who have had 3 consecutive negative annual Pap smears results may be screened every 2 or 3 years if they are 30 or older with no history of CIN 2 or 3, immunosuppression, HIV infection, or diethystilbestrol (DES) exposure in utero.
113
```
A 48 year-old G3P3003 female presents to the office complaining of severe secondary dysmenorrhea and menorrhagia over the last 6 months. On physical examination her uterus feels enlarged and irregular. Which of the following is the most likely diagnosis?
A. Endometritis
B. Endometriosis
C. Uterine leiomyomata
D. Endometrial hyperplasia
```
(c) C. Uterine leiomyomata (fibroid) typically presents with severe dysmenorrhea and menorrhagia. An enlarged, irregular uterus is noted on examination.
114
```
Your patient has just delivered her baby vaginally without difficulty. The patient has a laceration of the vaginal mucosa including the perineal body. You repair it without difficulty. On the chart you document this as what type of tear?
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
```
(c) B. A second degree tear involves the underlying subcutaneous tissues, but not the rectal sphincter or rectal mucosa.
115
```
What phase of the female menstrual cycle occurs at the time of elevated estrogen and LH/FSH surge?
A. Follicular phase
B. Proliferative phase
C. Ovulation
D. Secretory phase
```
(c) C. Ovulation occurs within 30-36 hours of the LH surge and at the time of elevated estrogen.
116
Colposcopic examination of the cervix of a 38 year-old woman with a high-grade lesion on Papanicolaou (Pap) smear yields a positive endocervical canal curettage (ECC) as its only abnormality. Which of the following is the most appropriate next step in this patient?
A. Repeat the Pap smear in 3 months
B. Perform a conization of the cervix
C. Repeat the colposcopic examination in 3months
D. No follow-up is required
(c) B. A conization of the cervix is recommended in this case because there is a substantial discrepancy between the screening Pap test and the histologic data from biopsy and ECC. Additionally the ECC is positive for disease in this case.
117
Which of the following physical examination findings is present in a 12 week singleton pregnancy?
A. Chadwick's sign
B. Uterus palpable at the level of the umbilicus
C. Blood pressure lower than non-pregnant state
D. Hyperreflexia
(c) A. Chadwick's sign is a bluish discoloration of the vagina early in pregnancy; it usually appears by 12 weeks of gestation.
118
```
You are following a patient in labor at term. You evaluate the fetal monitoring tracing and note the presence of variable, repetitive decelerations in the heart rates. The contractions have a sharp deceleration slope. What is the recommended treatment for these decelerations?
A. Change maternal position
B. Administer tocolytic therapy
C. Apply vibroacustic stimulation
D. Perform cesarean section
```
(c) A. Variable decelerations occur from umbilical cord compression and oligohydramnios. They are treated by changing maternal positioning to relieve pressure on the umbilical cord. Additionally, amnioinfusion may be used to relieve umbilical cord compression in cases of oligohydramnios.
119
What is the recommended initial first trimester screening test for fetal aneuploidy?
A. Amniocentesis
B. Pregnancy-associated plasma protein A (PPA), beta-hCG, and ultrasound of nuchal transparency
C. Maternal serum alpha feto protein, beta-hCG, estriol, and inhibin-A
D. Level II ultrasound
(c) B. Pregnancy-associated plasma protein A (PPA), beta-hCG, and ultrasound of nuchal transparency are screening tests done at 10-13 weeks of gestation.
120
```
In which of the following conditions would human chorionic gonadotropin (hCG) level be lower than expected for gestational age?
A. Choriocarcinoma
B. Hydatidiform mole
C. Ectopic pregnancy
D. Twin gestation
```
(c) C. An ectopic pregnancy will have an abnormally low hCG level because the hCG will not double every 48 hours as a normal pregnancy would.
121
```
A 47 year-old perimenopausal female with vasomotor symptoms complains of vulvar itching and copious vaginal discharge with a rancid odor. Physical examination reveals erythema of the vulva and petechiae on the cervix. The pH of the vaginal discharge is five. Which of the following is the recommended treatment for this patient?
A. Topical metronidazole (Metrogel)
B. Oral fluconazole (Diflucan)
C. Topical estradiol (Estrace) cream
D. Oral metronidazole (Flagyl)
```
(c) D. This is a classic description of trichomonas vulvovaginitis. This condition must be treated with oral metronidazole or tinidazole
122
Which of the following portends the greatest risk for the development of breast cancer?
A. Nulliparity
B. Earlymenarche
C. BRCA 1 positivity
D. Maternal family history of breast cancer
(c) C. BRCA1 positivity is associated with half of the early onset breast cancers and 90% of the hereditary ovarian cancers.
123
A patient presents to the office with a last menstrual period of May 4th. What is the estimated date of confinement? A. January4
B. January11
C. February 11
D. February 12
(c) C. Calculation is based on Naegele's rule by adding 7 days to the first day of the last menstrual period and then subtracting 3 months.
124
```
Which of the following tocolytic agents works by inhibition of calcium influx?
A. Nifedipine (Procardia)
B. Terbutaline sulfate (Terbutaline)
C. Indomethacin (Indocin)
D. Ritodrine (Yutopar)
```
(c) A. Nifedipine, a calcium channel blocker, prevents calcium entry into muscle cells. It is commonly used for the treatment of preterm labor.
125
A 28 year-old G1 P0 female at 36 weeks gestation, presents to labor and delivery after she experienced a sudden gush of fluid that soaked her underwear. She admits to urinary frequency, but denies any contractions, vaginal bleeding or dysuria. Which of the following is the most appropriate next step in the management of this patient?
A. Induction of labor with oxytocin (Pitocin)
B. Digital examination for the presence of cervical dilation
C. Urinalysis for urinary tract infection
D. Sterile speculum examination for vaginal pooling and ferning
(c) D. Fluid passing through the vagina is presumed to be amniotic fluid until proven otherwise. Urinary leakage is common during pregnancy, especially near term and can be difficult for the patient to decifer between urinary incontinence and premature rupture of membranes.
126
```
A 35 year-old primigravida presents to your office at 16 weeks gestation. BP measurements in the first trimester were within normal limits. On physical examination her blood pressure after 5 minutes of rest is 160/100 mmHg. A repeat measurement 1 week later is 154/98 mmHg. Fundoscopic exam is normal, and no other abnormalities are noted. Which of the following is the most likely diagnosis in this patient?
A. Preeclampsia
B. Chronic hypertension
C. Gestational hypertension
D. Molar pregnancy
```
(c) B. Chronic hypertension in a pregnant patient is defined as hypertension present before the 20th week of pregnancy or hypertension present before pregnancy.
127
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A 24 year-old G2 P1 at 32 weeks of gestation presents to labor and delivery with contractions. Her previous pregnancy resulted in an uncomplicated term delivery at 37 weeks. Which of the following will be most helpful in predicting the likelihood of preterm delivery in this patient?
A. Fetal fibronectin
B. Screening for candidiasis
C. Weekly digital cervical examinations
D. Ultrasound of lower uterine segment
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(c) A. An increase in the concentration of fetal fibronectin in cervicovaginal secretions is found with preterm labor. A preterm rise in the concentration may be associated with an increase likelihood of birth between 22 and 34 weeks of gestation and birth within 7-14 days of the test.
128
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An 18 year-old G1 P0 patient at 32 weeks gestation is sent to labor and delivery directly from her obstetrician's office. Her blood pressure on presentation is 162/114 mmHg; she is hyperreflexic and has 3+ protein on random urine dipstick. There is good fetal beat to beat variability with an occasional mild contraction on the uterine monitor. Which of the following would be the benefit of magnesium sulfate in this patient?
A. Cessation of contractions
B. Lowering of blood pressure
C. Stabilization of renal function
D. Prevention of seizures
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(c) D. This patient has findings consistent with severe preeclampsia. Magnesium sulfate is given to prevent and treat eclamptic convulsions. If the patient continues to have systolic blood pressure measurements >160 mmHg or if diastolic blood pressures exceeds 105-110 mm Hg an antihypertensive medication will need to be added. Magnesium sulfate can also be used to treat preterm labor, however an occasional mild contraction at this gestational age is not unusual and does not need to be treated.
129
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A 25 year-old G3 P2 patient presents for a routine obstetric appointment at 28 weeks gestation. Her EDC is based on her LMP. The fundal height is measured at 34 cm for this singleton pregnancy. Her weight gain has been normal thus far during this pregnancy. Which of the following laboratory or diagnostic studies is recommended to further evaluate this patient?
A. Ultrasonography
B. Nonstress test
C. Quadruple screen
D. Glucose tolerance test
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(c) A. Fetal growth can be assessed by fundal height measurement and correlates by centimeters to weeks of gestation in a singleton pregnancy. Deviation in fundal height measurement should be evaluated by ultrasound.
130
An 86 year-old female presents complaining of progressive, significant vulvar itching. The itching is temporarily relieved with scratching. On examination you note diffuse involvement of the vulva with very thin, whitish epithelial plaques. In several areas the skin appears cracked and bleeds easily in several areas. Which of the following is the appropriate intervention for this patient?
A. Topical conjugated estrogen (Premarin)
B. Topical clobetasol (Temovate)
C. Ultraviolet light treatment
D. Biopsy referral
(c) D. It is important to biopsy multiple areas of vulvar skin involvement to confirm diagnosis and to rule out the presence of vulvar cancer. Patients who are confirmed to have lichen sclerosis with a large acanthotic component should be treated with well-penetrating corticosteroid creams.
131
What physical exam finding indicates the delivery of the placenta is imminent in the third stage of labor?
A. Decrease in vaginal bleeding
B. Increase in uterine contractions
C. Shortening of the umbilical cord length
D. Uterus is higher and more globular in abdomen
(c) D. Delivery of the placenta occurs in the third stage of labor and is imminent when the uterus rises in the abdomen, becoming more globular in configuration, indicating that the placenta has separated and has entered the lower uterine segment. A gush of blood and/or lengthening of the umbilical cord, as well as a rising uterus are the three classic signs of placental separation.
132
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A 24 year-old woman presents to the ED with a several day duration of flu-like syndrome, several small tender ulcers on her vulva and an inability to void. She admits to several sexual contacts in the last 20 days. She denies prior sexually transmitted diseases. Examination reveals the presence of tender lymphadenopathy. Which of the following is most likely based upon the patient's physical exam findings?
A. Herpes simplex virus
B. Chancroid
C. Syphilis
D. Granuloma inguinale
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c) A. This patient presents with history and physical exam findings suggestive of HSV. This is her first episode so flu-like symptoms are classic, and usually occur within 2 to 3 days post infection. Painful vesicular and ulcerated lesions appear on the vulva, vagina, cervix, or perineal and perinanal skin, often extending to the buttocks. Painful lymphadenopathy is common. Dysuria caused by vulvar lesions or urethral or bladder involvement may lead to urinary retention.
133
An 18 year-old female presents with dysmenorrhea associated with nausea and diarrhea for the last 3 years. She is not taking any medications at this time. Examination reveals a midline, mobile, and non-tender uterus of normal size. She has no cervical motion tenderness. Which of the following is the most likely pathophysiology for this patient's symptoms?
A. Myometrial irritation from ectopic endometrial glands
B. Excessive prostaglandin-induced myometrial contraction
C. Pelvic congestion from dilated spiral arterioles
D. Excessive endometrial proliferation from unopposed estrogen
(c) B. Primary dysmenorrhea is caused by an excess of prostaglandin F2 alpha produced in the endometrium. Prostaglandin production in the uterus normally increases under the influence of progesterone, reaching a peak at the start of menses.
134
Which of the following is required for the initiation and maintenance of the menstrual cycle?
A. Prolactin release by the anterior pituitary
B. Pulsatile secretion of gonadotropin-releasing hormone (GnRH)
C. Follicular phase of variable length
D. Estrogen secretion by the ovary
(c) B. Gonadotropin-releasing hormone is secreted in a pulsatile fashion from the arcuate nucleus of the hypothalamus. The pulsatile secretion of GnRh stimulates and modulates pituitary gonadotropin secretion.
135
A 22 year-old nulliparous female undergoes laparoscopy for progressive dysmenorrhea and chronic pelvic pain. She is found to have minimal chocolate-colored cysts on the left ovary, which are cauterized at time of surgery. She is not currently sexually active, uses no contraception, but does plan to marry and have children soon. What is the recommended therapy for this patient at this time?
A. Naproxen sodium (Anaprox)
B. Leuprolide acetate depot (Lupron)
C. Levonorgestrel and ethinyl estradiol (Seasonique)
D. Danocrine (Danazol)
(c) C. Oral contraceptives are considered first line therapy for the treatment of endometriosis, often with the use of NSAIDs in combination. Continuous therapy, is often used to prevent secondary dysmenorrhea. Therapy causes a decidual reaction in the functioning endometriotic tissue decreasing symptoms.
136
Which of the following lab findings is suggestive of menopause?
A. Decrease in FSH, increase in LH
B. Decrease in FSH, decrease in LH
C. Increase in FSH, increase in estradiol
D. Increase in FSH, decrease in estradiol
(c) D. FSH greater than 30 mIU/mL is diagnostic of menopause. LH is also elevated in menopause. Estradiol starts to decrease around menopause to levels of 10-15 pg/mL.
137
Current recommendations concerning antepartum treatment of antibody negative, Rh-negative women with Rh- immune globulin include which of the following?
A. Administration at 28 and 36 weeks of gestation
B. Administration at 28 weeks gestation to all Rh-negative women
C. Administration within 72 hours of delivery of a Rh D negative infant
D. Administration in first pregnancy only
(c) B. Rh negative women are screened on initial and 28 week lab panels for antibodies to the Rh antigen. If the mother is antibody negative she will receive a Rhogam injection at 28 weeks and within 72 hours of the birth of a Rh positive baby. Rhogam is also prophylactically provided when any event takes place in the pregnancy where there is risk of fetomaternal hemorrhage that could lead to maternal exposure to fetal red blood cells including: abortion, ectopic pregnancy, bleeding associated with previa or abruption, amniocentesis, chorionic villus sampling, abdominal trauma, or external cephalic version.
138
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A 25 year-old woman has noted an enlarging painful swelling of the right labia for three days. Which of the following is the most likely diagnosis?
A. Condyloma acuminata
B. Gartner duct cyst
C. Bartholin gland abscess
D. Squamous cell carcinoma
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(c) C. Bartholin glands, located on the inferior borders of the vagina, are a common location for N. gonorrhoeae or C. trachomatis infection. When the gland becomes full or painful, incision and drainage is appropriate.
139
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A 28 year-old G0 P0 female presents with a 2 week history of pelvic pain and scant vaginal bleeding. She reports a history of regular menses every 28 days, however, her LMP was 37 days ago. On examination, her uterus is normal in size. There is a small amount of blood in the vagina. Her left adnexa is somewhat tender. Which of the following is the most likely diagnosis?
A. Ruptured corpus luteum cyst
B. Pelvic inflammatory disease
C. Ectopic pregancy
D. Threatened abortion
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(c) C. An ectopic pregancy is one in which the blastocyst implants anywhere other than the endometrial lining of the uterine cavity. The classic symptoms of an ectopic pregnancy are amenorrhea, followed by vaginal bleeding, and abdominal pain on the affected side.
