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Question 1

A pregnant patient of yours goes to the emergency room at 20 weeks gestational age with complaints of hematuria and back pain. The emergency room physician orders an intravenous pyelogram (IVP) as part of a workup for a possible kidney stone. The radiologist indicates the absence of nephrolithiasis but reports the presence of bilateral hydronephrosis and hydroureter, which is greater on the right side than on the left. Which of the following statements is true regarding this IVP finding?
A. The bilateral hydronephrosis is of concern, and renal function tests, including BUN and creatinine, should be run and closely monitored.
B. These findings are consistent with normal pregnancy and are not of concern.
C. The bilateral hydronephrosis is of concern, and a renal sonogram should be ordered emergently.
D. The findings indicate that a urology consult is needed to obtain recommendations for further workup and evaluation.
E. The findings are consistent with ureteral obstruction, and the patient should be referred for stent placement.

Answer 1

B. These findings are consistent with normal pregnancy and are not of concern.

Question 2

A patient was induced for being postterm at 42½ weeks. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical examination: a small amount of cartilage in the earlobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae. Based on this physical examination, what is the approximate gestational age of this male infant?
A. 28 weeks
B. 33 weeks
C. 36 weeks
D. 38 weeks
E. 42 weeks

Answer 2

D. 38 weeks

Question 3

You are delivering a 26-year-old G3P2002 at 40 weeks. She has a history of two previous uncomplicated vaginal deliveries and has had no complications this pregnancy. After 15 minutes of pushing, the baby’s head delivers spontaneously, but then retracts back against the perineum. As you apply gentle downward traction to the head, the baby’s anterior shoulder fails to deliver. Which of the following is the best next step in the management of this patient?
A. Call for help
B. Cut a symphysiotomy
C. Instruct the nurse to apply fundal pressure
D. Perform a Zavanelli maneuver
E. Push the baby’s head back into the pelvis

Answer 3

A. Call for help

Question 4

A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her early third trimester delivers a growth- restricted infant with seizures, intracranial calcifications, hepatosplenomegaly, jaundice, and anemia. What is the most likely causative agent?
A. Cytomegalovirus
B. Hepatitis B
C. Influenza A
D. Parvovirus
E. T. gondii

Answer 4

E. T. gondii

Question 5

A 22-year-old G1P0 has just undergone a spontaneous vaginal delivery. As the placenta is being delivered, a red fleshy mass is noted to be protruding out from behind the placenta. Which of the following is the best next step in management of this patient?
A. Begin intravenous oxytocin infusion
B. Call for immediate assistance from other medical personnel
C. Continue to remove the placenta manually
D. Have the anesthesiologist administer magnesium sulfate
E. Shove the placenta back into the uterus

Answer 5

B. Call for immediate assistance from other medical personnel

Question 6

A 27-year-old G1P0 at 34 weeks gestation presents to your office complaining of a 2-day history of nausea and emesis. On physical examination, you notice that she is icteric sclera and skin. Her vital signs indicate a temperature of 37.2°C (99°F), pulse of 102 beats per minute, and blood pressure of 130/84 mm Hg. She is sent to labor and delivery for additional evaluation. In labor and delivery, the fetal heart rate is in the 160s with good variability, but nonreactive. Blood is drawn and the following results are obtained: WBC=22,000, Hct=40.0, platelets=72,000, SGOT/PT= 334/386, glucose=58, creatinine=2.2, fibrinogen=209, PT/PTT=16/50 s, serum ammonia level=65 mmol/L (nI=11-35). Urinalysis is positive for 3+ protein and large ketones. Which of the following is the recommended treatment for this patient?
A. Immediate delivery
B. Cholecystectomy
C. Intravenous diphenhydramine
D. MgSO4 therapy
E. Bed rest and supportive measures since this condition is self-limited

Answer 6

A. Immediate delivery

Question 7

A 43-year-old G1P0 who conceived via in vitro fertilization comes into the office for her routine OB visit at 38 weeks. She denies any problems since she was seen the week before. She reports good fetal movement and denies any leakage of fluid per vagina, vaginal bleeding, or regular uterine contractions. She reports that sometimes she feels crampy at the end of the day when she gets home from work, but this discomfort is alleviated with getting off her feet. The fundal height measurement is 36 cm; it measured 37 cm the week before. Her cervical examination is 2 cm dilated. Which of the following is the most appropriate next step in the management of this patient?
A. Instruct the patient to return to the office in 1 week for her next routine visit.
B. Admit the patient for induction caused by a diagnosis of fetal growth lag.
C. Send the patient for a sonogram to determine the amniotic fluid index.
D. Order the patient to undergo a nonstress test.
E. Do a fern test in the office.

Answer 7

A. Instruct the patient to return to the office in 1 week for her next routine visit.

Question 8

A 29-year-old G1P0 presents to the obstetrician’s office at 41 weeks gestation. On physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in position. The vertex is presenting at -3 station. Which of the following is the best next step in the management of this patient?
A. Send the patient to the hospital for induction of labor since she has a favorable Bishop score.
B. Teach the patient to measure fetal kick counts and deliver her if at any time there are less than 20 perceived fetal movements in 3 hours.
C. Order BPP testing for the same or next day.
D. Schedule the patient for induction of labor at 43 weeks gestation.
E. Schedule cesarean delivery for the following day since it is unlikely that the patient will go into labor.

Answer 8

C. Order BPP testing for the same or next day.

Question 9

The shortest distance between the sacral promontory and the symphysis pubis is called which of the following?
A. Interspinous diameter
B. True conjugate
C. Diagonal conjugate
D. Obstetric (OB) conjugate
E. Biparietal diameter

Answer 9

D. Obstetric (OB) conjugate

Question 10

You are seeing a patient in the hospital for decreased fetal movement at 36 weeks gestation. She is healthy and has had no prenatal complications. You order a BPP. The patient receives a score of 8 on the test. Two points were deducted for lack of fetal breathing movements. How should you counsel the patient regarding the results of the BPP?
A. The results are equivocal, and she should have a repeat BPP within 24 hours.
B. The results are abnormal, and she should be induced.
C. The results are normal, and she can go home.
D. The results are abnormal, and she should undergo emergent cesarean section.
E. The results are abnormal, and she should undergo umbilical artery Doppler velocimetry.

Answer 10

C. The results are normal, and she can go home.

Question 11

An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient’s estimated date of delivery?
A. February 10 of the next year
B. February 14 of the next year
C. December 10 of the same year
D. December 14 of the same year
E. December 21 of the same year

Answer 11

B. February 14 of the next year

Question 12

A 37-year-old G4P2 presents to your office for new OB visit at 8 weeks. In a prior pregnancy, the fetus had multiple congenital anomalies consistent with trisomy 18, and the baby died shortly after birth. The mother is worried that the current pregnancy will end the same way, and she wants testing performed to see whether this baby is affected. Which of the following can be used for chromosome analysis of the fetus?
A. Biophysical profile
B. Chorionic villus sampling
C. Fetal umbilical Doppler velocimetry
D. Maternal serum screen
E. Nuchal translucency

Answer 12

B. Chorionic villus sampling

Question 13

A 29-year-old G1P0 patient at 24 weeks gestational age presents to your office complaining of some shortness of breath that is more intense with exertion. She has no significant past medical history and is not on any medication. The patient denies any chest pain. She is concerned because she has always been very athletic and cannot maintain the same degree of exercise that she was accustomed to prior to becoming pregnant. On physical examination, her pulse is 72 beats per minute. Her blood pressure is 90/50 mm Hg. Cardiac examination is normal. The lungs are clear to auscultation and percussion. Which of the following is the most appropriate next step to pursue in the workup of this patient?
A. Refer the patient for a ventilation-perfusion scan to rule out a pulmonary embolism
B. Perform an arterial blood gas
C. Refer the patient to a cardiologist
D. Reassure the patient
E. Order an ECG

Answer 13

D. Reassure the patient

Question 14

You are following a 22-year-old G2P1 at 39 weeks during her labor. She is given an epidural for pain management. Three hours after administrating the pain medication, the patient’s cervical examination is unchanged. Her contractions are now every 2 to 3 minutes, lasting 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and early decelerations. Which of the following is the best next step in management of this patient?
A. Place a fetal scalp electrode
B. Rebolus the patient’s epidural
C. Place an IUPC
D. Prepare for a cesarean section secondary to a diagnosis of secondary arrest of labor
E. Administer Pitocin for augmentation of labor

Answer 14

C. Place an IUPC

Question 15

A 25-year-old G1 at 37 weeks presents to labor and delivery with gross rupture of membranes. The fluid is noted to be clear and the patient is noted to have regular painful contractions every 2 to 3 minutes lasting for 60 seconds each. The fetal heart rate tracing is reactive. On cervical examination she is noted to be 4 cm dilated, 90% effaced with the presenting part a -3 station. The presenting part is soft and felt to be the fetal buttock. A quick bedside ultrasound reveals a breech presentation with both hips flexed and knees extended. What type of breech presentation is described?
A. Frank
B. Incomplete, single footling
C. Complete
D. Double footling

Answer 15

A. Frank

Question 16

A 22-year-old G1P0 presents to your clinic for follow-up of evacuation of a complete hydatidiform mole. She is asymptomatic and her examination is normal. Which of the following would be an indication to start single-agent chemotherapy?
A. A rise in hCG titers
B. A plateau of hCG titers for 1 week
C. Return of hCG titer to normal at 6 weeks after evacuation
D. Appearance of liver metastasis
E. E Appearance of brain metastasis

Answer 16

A. A rise in hCG titers

Question 17

A 41-year-old G1P0 at 39 weeks, who has been completely dilated and pushing for 3 hours, has an epidural in place and remains undelivered. She is exhausted and crying and tells you that she can no longer push. Her temperature is 38.3°C (101°F). The fetal heart rate is in the 190s with decreased variability. The patient’s membranes have been ruptured for over 24 hours, and she has been receiving intravenous penicillin for a history of colonization with group B streptococcus bacteria. The patient’s cervix is completely dilated and effaced and the fetal head is in the direct OA position and is visible at the introitus between pushes. Extensive caput is noted, but the fetal bones are at the +3 station. Which of the following is the most appropriate next step in the management of this patient?
A. Deliver the patient by cesarean section
B. Encourage the patient to continue to push after a short rest
C. Attempt operative delivery with forceps
D. Rebolus the patient’s epidural
E. Cut a fourth-degree episiotomy

Answer 17

C. Attempt operative delivery with forceps

Question 18

A 24-year-old primigravid woman, who is intent on breast-feeding, decides on a home delivery. Immediately after the birth of a 4.1-kg (9-Ib) infant, the patient bleeds massively from extensive vaginal and cervical lacerations. She is brought to the nearest hospital in shock. Over 2 hours, 9 units of blood are transfused, and the patient’s blood pressure returns to a reasonable level. A hemoglobin value the next day is 7.5 g/dL, and 3 units of packed red blood cells are given. The most likely late sequela to consider in this woman is which of the following?
A. Hemochromatosis
B. Stein-Leventhal syndrome
C. Sheehan syndrome
D. Simmonds syndrome
E. Cushing syndrome

Answer 18

C. Sheehan syndrome

Question 19

A 20-year-old woman who works as a kindergarten teacher presents for her routine visit at 32 weeks. Her fundal height measures 40 cm. An ultrasound reveals polyhydramnios, an appropriately grown fetus with ascites and scalp edema. The patient denies any recent illnesses, but some of the children at her school have been sick recently. What is the most likely cause of the fetal findings?
A. Cytomegalovirus
B. Hepatitis B
C. Influenza A
D. Parvovirus
E. Toxoplasmosis gondii

Answer 19

D. Parvovirus

Question 20

You are counseling a new mother and father on the risks and benefits of circumcision for their 1-day-old son. The parents ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?
A. Analgesia is not recommended because there is no evidence that newborns undergoing circumcision experience pain.
B. Analgesia is not recommended because it is unsafe in newborns.
C. Analgesia in the form of oral Tylenol is the pain medicine of choice recommended for circumcisions.
D. Analgesia in the form of a penile block is recommended.
E. The administration of sugar orally during the procedure will keep the neonate preoccupied and happy.

Answer 20

D. Analgesia in the form of a penile block is recommended.

Question 21

A 34-year-old G1P1 who delivered her first baby 5 weeks ago calls your office and asks to speak with you. She tells you that she is feeling very overwhelmed and anxious. She feels that she cannot do anything right and feels sad throughout the day. She tells you that she finds herself crying all the time and is unable to sleep at night. Which of the following is the most likely diagnosis?
A. Postpartum depression
B. Maternity blues
C. Postpartum psychosis
D. Bipolar disease
E. Postpartum blues

Answer 21

A. Postpartum depression

Question 22

A maternal fetal medicine specialist is consulted and performs an in-depth sonogram on a 30-year-old G1 at 28 weeks with a twin gestation. The sonogram indicates that the fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. Which of the following would be a finding most likely associated with twin A?
A. Congestive heart failure
B. Anemia
C. Hypovolemia
D. Hypotension
E. Low amniotic fluid level

Answer 22

A. Congestive heart failure

Question 23

A 34-year-old G2P1 at 31 weeks gestation presents to labor and delivery with complaints of vaginal bleeding earlier in the day that resolved on its own. She denies any leakage of fluid or uterine contractions. She reports good fetal movement. In her last pregnancy, she had a low transverse cesarean delivery for breech presentation at term. She denies any medical problems. Her vital signs are normal and electronic external monitoringreveals a reactive fetal heart rate tracing and no uterine contractions. Which of the following is the most appropriate next step in the management of this patient?
A. Send her home, since the bleeding has completely resolved and she is experiencing good fetal movements
B. Perform a sterile digital examination
C. Perform an amniocentesis to rule out infection
D. Perform a sterile speculum examination
E. Perform an ultrasound examination

Answer 23

E. Perform an ultrasound examination

Question 24

A 23-year-old G1P0 reports to your office for a routine OB visit at 28 weeks gestational age. Labs drawn at her prenatal visit 2 weeks ago reveal a 1-hour glucose test of 128, hemoglobin of 10.8, and a platelet count of 80,000. All her other labs were within normal limits. During the present visit, the patient has a blood pressure of 120/70 mm Hg. Her urine dip is negative for protein, glucose, and blood. The patient denies any complaints. The only medication she is currently taking is a prenatal vitamin. She does report a history of epistaxis on occasion, but no other bleeding. Which of the following medical treatments should you recommend to treat the thrombocytopenia?
A. No treatment is necessary
B. Stop prenatal vitamins
C. Oral corticosteroid therapy
D. Intravenous immune globulin
E. Splenectomy

Answer 24

A. No treatment is necessary

Question 25

A 27-year-old woman (G3P2) comes to the delivery floor at 37 weeks gestation. She has had no prenatal care.**She complains that, on bending down to pick up her 2-year-old child, she experienced sudden, severe back pain that now has persisted for 2 hours.** Approximately 30 minutes ago she noted bright red blood coming from her vagina. By the time she arrives at the delivery floor, she is contracting strongly every 3 minutes; the uterus is quite firm even between contractions. By abdominal palpation, the fetus is vertex with the head deeply engaged. Fetal heart rate is 130 beats per minutes. The fundus is 38 cm above the symphysis. Blood for clotting is drawn, and a clot forms in 4 minutes. Clotting studies are sent to the laboratory. Which of the following actions can most likely wait until the patient is stabilized? A. Stabilizing maternal circulation B. Attaching a fetal electronic monitor C. Inserting an intrauterine pressure catheter D. Administering oxytocin E. Preparing for cesarean section

Answer 25

D. Administering oxytocin

Question 26

A patient at 17 weeks gestation is diagnosed as having an** intrauterine fetal demise**. She returns to your office 5 weeks later and her vital signs are: blood pressure 110/72 mm Hg, pulse 93 beats per minute, temperature 36.38°C, respiratory rate 16 breaths per minute. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on examination. This patient is at increased risk for which of the following? A. Septic abortion B. Recurrent abortion C. Consumptive coagulopathy with hypofibrinogenemia D. Future infertility E. Ectopic pregnancies

Answer 26

C. Consumptive coagulopathy with hypofibrinogenemia

Question 27

On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops **acute shortness of breath and chest pain.** Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6°C (99.8°F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis? A. Arterial blood gas B. Chest X-ray C. CT angiography D. Lower extremity Dopplers E. Ventilation-perfusion scan

Answer 27

C. CT angiography

Question 28

**Uterine bleeding** at **7 weeks gestation** without any **cervical dilation**. What is the type of abortion? A. Complete abortion B. Incomplete abortion C. Threatened abortion D. Missed abortion E. Inevitable abortion

Answer 28

C. Threatened abortion

Question 29

A healthy 25-year-old G1P0 at 40 weeks gestational age comes to your office to see you for a routine obstetric (OB) visit. The patient complains to you that on several occasions she has experienced dizziness, light-headedness, and feeling as if **she is going to pass out when she lies down on her back to take a nap.** What is the most appropriate plan of management for this patient? A. Do an ECG B. Monitor her for 24 hours with a Holter monitor to rule out an arrhythmia C. Do an arterial blood gas analysis D. Refer her immediately to a neurologist E. Reassure her that nothing is wrong with her and encourage her not to lie flat on her back

Answer 29

E. Reassure her that nothing is wrong with her and encourage her not to lie flat on her back

Question 30

A 40-year-old G4P5 at 39 weeks gestation has progressed rapidly in labor with a reassuring fetal heart rate pattern. She has had an uncomplicated pregnancy with normal prenatal labs, including an amniocentesis for advanced maternal age. The patient begins the second stage of labor and after 15 minutes of pushing starts to demonstrate deep variable heart rate accelerations. You suspect that she may have a fetus with a nuchal cord. You expediently deliver the baby by low-outlet forceps and hand the baby over to the neonatologists called to attend the delivery. As soon as the baby is handed off to the pediatric team, it lets out a strong spontaneous cry. The infant is pink with slightly blue extremities that are actively moving and kicking. The heart rate is noted to be 110 on auscultation. What Apgar score should the pediatricians assign to this baby at 1 minute of life? A. 10. B. 9 C. 8 D. 7 E. 6

Answer 30

B. 9

Question 31

Match this ethical concern or principal with the appropriate definition: the duty to promote the good of the patient A. Patient preferences B. Beneficence C. Quality of life D. Nonmaleficence E. Autonomy F. Medical indication G. Contextual issues H. Justice

Answer 31

B. Beneficence

Question 32

A 20-year-old G2P1 patient comes to see you at 17 weeks gestational age to review the results of her triple test done 1 week ago. You tell the patient that her **MSAFP level is 2.0 MOM**. The patient's obstetrical history consists of a term vaginal delivery 2 years ago without complications. Which of the following is correct advice for your patient regarding how to proceed next? A. Explain to the patient that the blood test is diagnostic of a neural tube defect and she should consult with a pediatric neurosurgeon as soon as possible. B. Tell the patient that the blood test result is most likely a false-positive result and she should repeat the test at 20 weeks. C. Refer the patient for an ultrasound to confirm dates. D. Offer the patient immediate CVS to obtain a fetal karyotype. E. Recommend to the patient that she undergo a cordocentesis to measure fetal serum AFP levels.

Answer 32

C. Refer the patient for an ultrasound to confirm dates.

Question 33

A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a **previous ectopic pregnancy** and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time? A. No action is needed because the patient is asymptomatic, has not missed her period, and cannot be pregnant. B. Order a serum quantitative pregnancy test. C. Listen for fetal heart tones by Doppler equipment. D. Perform an abdominal ultrasound. E. Perform a bimanual pelvic examination to assess uterine size.

Answer 33

B. Order a serum quantitative pregnancy test.

Question 34

You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant? A. Administration of ceftriaxone cream to the eyes for prophylaxis for gonorrhea and chlamydia B. Administration of vitamin A to prevent bleeding problems C. Administration of hepatitis B vaccination for routine immunization D. Cool-water bath to remove vernix E. Placement of a computer chip in left buttock for identification purposes

Answer 34

C. Administration of hepatitis B vaccination for routine immunization

Question 35

A healthy 20-year-old G1P0 presents for her first OB visit at 10 weeks gestational age. She denies any significant medical history both personally and in her family. Which of the following tests is not part of the recommended first trimester blood testing for this patient? A. Complete blood count (CBC) B. Screening for human immunodeficiency virus (HIV) C. Hepatitis B surface antigen D. Blood type and screen E. One-hour glucose challenge testing

Answer 35

E. One-hour glucose challenge testing

Question 36

You are counseling a 24-year-old woman who is a G2P1 at 36 weeks gestation. She delivered her first baby at 41 weeks gestation by cesarean section as a result of fetal distress that occurred during an induction of labor for mild preeclampsia. She would like to know if she can have a trial of labor with this pregnancy. Which of the following is the best response to this patient? A. No, since she has never had a vaginal delivery. B. Yes, but only if she had a low transverse cesarean section. C. No, because once she has had a cesarean section she must deliver all of her subsequent children by cesarean section. D. Yes, but only if her uterine incision was made in the uterine fundus. E. Yes, but only if she had a classical cesarean section.

Answer 36

B. Yes, but only if she had a low transverse cesarean section.

Question 37

Uterine bleeding at 12 weeks gestation accompanied by cervical dilation without **passage of tissue**. What is the type of abortion? A. Complete abortion B. Incomplete abortion C. Threatened abortion D. Missed abortion E. Inevitable abortion

Answer 37

E. Inevitable abortion

Question 38

One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order? A. MRI B. Computed tomographic scanning C. Venography D. Real-time ultrasonography E. X-ray of lower extremity

Answer 38

D. Real-time ultrasonography

Question 39

An 18-year-old G2P1 presents to the emergency department with abdominal pain and vaginal bleeding for the past day. Her last menstrual period was 7 weeks ago. On examination she is afebrile with normal blood pressure and pulse. Her abdomen is tender in the left lower quadrant with voluntary guarding. On pelvic examination, she has a small anteverted uterus, no adnexal masses, mild left adnexal tenderness, and mild cervical motion tenderness. Labs reveal a normal white count, hemoglobin of 10.5, and a quantitative B-hCG of 2342. Ultrasound reveals a 10×5×6 cm uterus with a normal-appearing 1-cm stripe and no gestation sac or fetal pole. A 2.8-cm complex adnexal mass is noted on the left. In the treatment of this patient, laparoscopic salpingostomy has what advantage over salpingectomy via laparotomy? A. Decreased hospital stays B. Lower fertility rate C. Lower repeat ectopic pregnancy rate D. Comparable persistent ectopic tissue rate E. Greater scar formation

Answer 39

A. Decreased hospital stays

Question 40

A 20-year-old G1PO presents to your clinic for follow-up for a **suction dilation and curettage for an incomplete abortion**. She is asymptomatic without any vaginal bleeding, fever, or chills. Her examination is normal. The pathology report reveals trophoblastic proliferation and hydropic degeneration with the absence of vasculature; no fetal tissue is identified. A chest x-ray is negative for any evidence of metastatic disease. Which of the following is the best next step in her management? A. Weekly human chorionic gonadotropin (hCG) titers B. Hysterectomy C. Single-agent chemotherapy D. Combination chemotherapy E. Radiation therapy

Answer 40

A. Weekly human chorionic gonadotropin (hCG) titers

Question 41

A 19-year-old G1PO presents to her obstetrician's office for a routine OB visit at 32 weeks gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompliant with diet and insulin therapy. She has had two prior normal ultrasounds at 20 and 28 weeks gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm. Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age? A. Fetal hydrocephaly B. Uterine fibroids C. Polyhydramnios D. Breech presentation E. Undiagnosed twin gestation

Answer 41

Polyhydramnios

Question 42

A 24-year-old primigravida with twins presents for routine ultrasonography at 20 weeks gestation. Based on the ultrasound findings, the patient is diagnosed with dizygotic twins. Which of the following is true regarding the membranes and placentas of dizygotic twins? A. They are dichorionic and monoamniotic only if the fetuses are of the same sex. B. They are dichorionic and monoamniotic regardless of the sex of the fetuses. C. They are monochorionic and monoamniotic if they are conjoined twins. D. They are dichorionic and diamniotic regardless of the sex of the twins. E. They are monochorionic and diamniotic if they are of the same sex.

Answer 42

D. They are dichorionic and diamniotic regardless of the sex of the twins.

Question 43

A 20-year-old G1 at 32 weeks presents for her routine obstetric (OB) visit. She has no medical problems. She is noted to have a blood pressure of 150/96 mm Hg, and her urine dip shows 1+ protein. She complains of a constant headache and vision changes that are not relieved with rest or a pain reliever. The patient is sent to the hospital for further management. At the hospital, her blood pressure is 158/98 mm Hg and she is noted to have tonic-clonic seizure. Which of the following is indicated in the management of this patient? A. Low-dose aspirin B. Dilantin (phenytoin) C. Antihypertensive therapy D. Magnesium sulfate E. Cesarean delivery

Answer 43

D. Magnesium sulfate

Question 44

A 34-year-old G2 at 36 weeks delivers a growth-restricted infant with cataracts, anemia, patent ductus arteriosus, and **sensorineural deafness**. She has a history of chronic hypertension, which was well controlled with methyldopa during pregnancy. She had a viral syndrome with rash in early pregnancy. What is the most likely causative agent? A. Parvovirus B. Rubella virus C. Rubeola D. Toxoplasma gondii E. T. pallidum

Answer 44

B. Rubella virus

Question 45

An 18-year-old G1 at 8 weeks gestation complains of nausea and vomiting over the past week occurring on a daily basis. Nausea and emesis are a common symptom in early pregnancy. Which of the following signs or symptoms would indicate a more serious diagnosis of **hyperemesis gravidarum**? A. Hypothyroidism B. Hypokalemia C. Weight gain D. Proteinuria E. Diarrhea

Answer 45

B. Hypokalemia

Question 46

Your patient is a 44-year-old G4P4 with symptomatic uterine fibroids that are unresponsive to medical therapy. The patient has severe menorrhagia to the point that when she menstruates, she cannot leave the house. You recommend to her that she undergo a total abdominal hysterectomy. You counsel her that she may need a blood transfusion i she has a large blood loss during the surgical procedure. Her current hematocrit is 25.0. The patient is a Jehovah's Witness who adamantly refuses to have a blood transfusion, even if it results in her death. Respect for the patient's autonomy or own wishes requires that which of the following be assessed? A. The needs of society B. The duty not to inflict harm C. The impact that the treatment will have on the patient's quality of life D. Consideration of what is the best treatment E. The patient's personal values

Answer 46

E. The patient's personal values

Question 47

A 21-year-old G2P2 calls her physician 7 days postpartum because she is concerned that she is still bleeding from the vagina. She describes the bleeding as **light pink to bright red** and less heavy than the first few days postdelivery. She denies fever or any cramping pain. On examination she is afebrile and has an appropriately sized, nontender uterus. The vagina contains about 10 cc of old, dark blood. The cervix is closed. Which of the following is the most appropriate treatment? A. Antibiotics for endometritis B. High-dose oral estrogen for placental subinvolution C. Oxytocin for uterine atony D. Suction dilation and curettage for retained placenta E. Reassurance

Answer 47

E. Reassurance

Question 48

A 24-year-old woman (G3P2) is at 40 weeks gestation. The fetus is in the transverse lie presentation. What is the most appropriate procedure? A. External version B. Internal version C. Midforceps rotation D. Low transverse cesarean section E. Classic cesarean section

Answer 48

A. External version

Question 49

A 22-year-old has just been diagnosed with toxoplasmosis. You try to determine what her risk factors were. The highest risk association is which of the following? A. Eating raw meat B. Eating raw fish C. Owning a dog D. English nationality E. Having viral infections in early pregnancy

Answer 49

A. Eating raw meat

Question 50

A 28-year-old female has agreed to be a gestational surrogate for a couple who cannot bear children. She presents to your office for prenatal care. Which of the following is your responsibility as an obstetrician caring for a gestational surrogate? A. Consult with intended parents regarding all clinical interventions and management of the pregnancy. B. Discuss the health of the surrogate and progress of the pregnancy with the intended parents without consent of the surrogate mother. C. Make recommendations for prenatal care in accordance with the agreement between the gestational surrogate and the intended parents. D. Only provide prenatal care to her, if the adoptive mother is also your patient. E. Provide appropriate care regardless of the patient's plans to keep or relinquish the future child.

Answer 50

E. Provide appropriate care regardless of the patient's plans to keep or relinquish the future child.

Question 51

A 26-year-old G1P0 patient at 34 weeks gestation is being evaluated with Doppler ultrasound studies of the fetal umbilical arteries. The patient is a healthy smoker. Her fetus has shown evidence of intrauterine growth restriction (IUGR) on previous ultrasound examinations. The Doppler studies currently show that the systolic to diastolic ratio (S/D) in the umbilical arteries is much higher than it was on her last ultrasound 3 weeks ago and there is now reverse diastolic flow. Which of the following is correct information to share with the patient? A. The Doppler studies indicate that the fetus is doing well. B. With advancing gestational age the S/D ratio is supposed to rise. C. These Doppler findings are normal in someone who smokes. D. Reverse diastolic flow is normal as a patient approaches full term. E. The Doppler studies are worrisome and indicate that the fetal status is deteriorating.

Answer 51

E. The Doppler studies are worrisome and indicate that the fetal status is deteriorating.

Question 52

A 22-year-old woman delivers a 7-Ib male infant at 40 weeks without any complications. On day 3 of life, the infant develops respiratory distress, hypotension, tachycardia, **listlessness**, and oliguria. What is the most likely cause of the infant's illness? A. Cytomegalovirus B. Group B streptococcus C. Hepatitis B D. Herpes simplex E. L. monocytogenes

Answer 52

B. Group B streptococcus

Question 53

Match this ethical concern or principal with the appropriate definition: respect of the patient's right to **self-determination** A. Patient preferences B. Beneficence C. Quality of life D. Nonmaleficence E. Autonomy F. Medical indication G. Contextual issues H. Justice

Answer 53

E. Autonomy

Question 54

A 38-year-woman at 39 weeks delivers a 7-lb infant female without complications. At 2 weeks of life, the infant develops **fulminant liver failure** and dies. What is the most likely causative virus? A. Cytomegalovirus B. Hepatitis B C. Herpes simplex D. Parvovirus E. Rubeola

Answer 54

B. Hepatitis B

Question 55

Following a vaginal delivery, a woman develops a fever, lower abdominal pain, and uterine tenderness. She is alert, and her blood pressure and urine output are good. **Large gram-positive rods suggestive of clostridia are seen in a smear of the cervix**. Which of the following is most closely tied to a decision to proceed with hysterectomy? A. Close observation for renal failure or hemolysis B. Immediate radiographic examination for hydrosalpinx C. High-dose antibiotic therapy D. Fever of 103°F E. Gas gangrene

Answer 55

E. Gas gangrene

Question 56

A 30-year-old G3P3, who is 8 weeks postpartum and regularly breast-feeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness. Which of the following should you recommend to help her with this problem? A. Instruct her to stop breast-feeding B. Apply hydrocortisone cream to the perineum C. Apply testosterone cream to the vulva and vagina D. Apply estrogen cream to the vagina and vulva E. Apply petroleum jelly to the perineum

Answer 56

D. Apply estrogen cream to the vagina and vulva

Question 57

What is the recommendation regarding rubella vaccination in pregnancy? A. Recommended if the underlying disease is serious B. Recommended after exposure or before travel to endemic areas C. Not routinely recommended, but mandatory during an epidemic D. Contraindicated unless exposure to the disease is unavoidable E. Contraindicated

Answer 57

E. Contraindicated

Question 58

A 30-year-old G2P0 at 39 weeks is admitted in active labor with spontaneous rupture of membranes occurring 2 hours prior to admission. The patient noted clear fluid at the time. On examination, her cervix is 4 cm dilated and completely effaced. The fetal head is at 0 station and the fetal heart rate tracing is reactive. Two hours later on repeat examination her cervix is 5 cm dilated and the fetal head is at +1 station. Early decelerations are noted on the fetal heart rate tracing. Which of the following is the best next step in her labor management? A. Administer terbutaline B. Initiate amnioinfusion C. Initiate Pitocin augmentation D. Perform cesarean delivery for arrest of descent E. Perform cesarean delivery of early decelerations

Answer 58

C. Initiate Pitocin augmentation

Question 59

Your patient's father was just diagnosed with dementia associated with emotional disturbances and choreic body movements. She was told his disease is hereditary. Match this clinical situation with the appropriate inheritance pattern. A. Autosomal dominant B. Autosomal recessive C. X-linked recessive D. Codominant E. Multifactorial

Answer 59

A. Autosomal dominant

Question 60

A 28-year-old G1P0 presents to your office at 18 weeks gestational age for an unscheduled visit secondary to **right-sided groin pain.** She describes the pain as sharp and occurring with movement and exercise. She denies any change in urinary or bowel habits. She also denies any fever or chills. The application of a heating pad helps alleviate the discomfort. As her obstetrician, what should you tell this patient is the most likely etiology of this pain? A. Round ligament pain B. Appendicitis C. Preterm labor D. Kidney stone E. Urinary tract infection

Answer 60

A. Round ligament pain

Question 61

A 30-year-old G3P3 is postoperative day 4 after a repeat cesarean delivery. During the surgery she received 2 units of packed red blood cells for a hemorrhage related to uterine atony. She is to be discharged home today. She complains of some yellowish drainage from her incision and redness that just started earlier in the day. She states that she feels feverish. She is breast-feeding. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8°C (100.1°F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Breast, lung, and cardiac examinations are normal. Her midline vertical skin incision is erythematous and has a foul-smelling purulent discharge from the lower segment of the wound. It is tender to touch. The uterine fundus is not tender. Which of the following is not a risk factor for her condition? A. Diabetes B. Corticosteroid therapy C. Preoperative antibiotic administration D. Anemia E. Obesity

Answer 61

C. Preoperative antibiotic administration

Question 62

Expulsion of all fetal and placental tissue from the uterine cavity at 10 weeks gestation. What is the type of abortion? A. Complete abortion B. Incomplete abortion C. Threatened abortion D. Missed abortion E. Inevitable abortion

Answer 62

A. Complete abortion

Question 63

Match this ethical concern or principal with the appropriate definition: the duty not to inflict harm or injury A. Patient preferences B. Beneficence C. Quality of life D. Nonmaleficence E. Autonomy F. Medical indication G. Contextual issues H. Justice

Answer 63

D. Nonmaleficence

Question 64

A 50-year-old woman complains of leakage of urine. After genuine stress urinary incontinence, which of the following is the most common cause of urinary leakage? A. Detrusor dyssynergia B. Unstable bladder C. Unstable urethra D. Urethral diverticulum E. Overflow incontinence

Answer 64

B. Unstable bladder

Question 65

What is the most appropriate rate of use effectiveness (percentage of pregnancies per year of actual patient use) for condoms and spermicidal agents? A. 80% B. 40% C. 15% to 25% D. 5% to 15% E. 3% to 10%

Answer 65

D. 5% to 15%

Question 66

A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies? A. Cervix B. Ovary C. Breast D. Vagina E. Colon

Answer 66

A. Cervix

Question 67

A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a **small vulvar ulceration that spontaneously healed**. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of **lymphogranuloma venereum (LGV)**. The diagnosis can be established by which of the following? A. Staining for Donovan bodies B. The presence of serum antibodies to Chlamydia trachomatis C. Positive Frei skin test D. Culturing Haemophilus ducreyi E. Culturing Calymmatobacterium granulomatis

Answer 67

B. The presence of serum antibodies to Chlamydia trachomatis

Question 68

A 36-year-old G2P2 presents for her well-woman examination. She has had two spontaneous vaginal deliveries without complications. Her largest child weighed 3500 g at birth. She uses oral contraceptive pills and denies any history of an abnormal Pap smear. She does not smoke, but drinks about four times per week. Her weight is 70 kg. Her vital signs are normal. After placement of the speculum, you note a clear cyst approximately 2.5 cm in size on the lateral wall of the vagina on the right side. The cyst is nontender and does not cause the patient any dyspareunia or discomfort. Which of the following is the most likely diagnosis of this mass? A. Bartholin duct cyst B. Gartner duct cyst C. Lipoma D. Hematoma E. Inclusion cyst

Answer 68

B. Gartner duct cyst

Question 69

A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm adnexal cyst is palpated. Ultrasound confirms a complex left adnexal mass with solid components that appear to contain bone and teeth. What percentage of these tumors are bilateral? A. Less than 1% B. 2% to 3% C. 10% to 15% D. 50% E. Greater than 75%

Answer 69

C. 10% to 15%

Question 70

A 40-year-old G3P3 comes to your office for a routine annual GYN examination. She tells you that she gets up several times during the night to void. On further questioning, she admits to you that during the day she sometimes gets the urge to void, but sometimes cannot quite make it to the bathroom. She attributes this to getting older and is not extremely concerned, although she often wears a pad when she goes out in case she loses some urine. This patient is very healthy otherwise and does not take any medication on a regular basis. She still has regular, monthly menstrual periods. She has had three normal spontaneous vaginal deliveries of infants weighing between 7 and 8 lb. An office dipstick of her urine does not indicate any blood, bacteria, WBCs, or protein. Her urine culture is negative. Based on her office presentation and history, which of the following is the most likely diagnosis? A. Urinary stress incontinence B. Urinary tract infection C. Overflow incontinence D. Bladder dyssynergia E. Vesicovaginal fistula

Answer 70

D. Bladder dyssynergia

Question 71

A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your colposcopic impression is of acetowhite changes suggestive of human papilloma virus infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which of the following is the most appropriate next step in the management of this patient? A. Cryotherapy of the cervix B. Laser ablation of the cervix C. Conization of the cervix D. Hysterectomy E. Repeat the Pap smear in 3 to 6 months

Answer 71

C. Conization of the cervix

Question 72

A 90-year-old G5P5 with multiple medical problems is brought into your gynecology clinic accompanied by her granddaughter. The patient has hypertension, chronic anemia, coronary artery disease, and osteoporosis. She is mentally alert and oriented and lives in an assisted living facility. She takes numerous medications, but is very functional at the current time. She is a widow and not sexually active. Her chief complaint is a sensation of heaviness and pressure in the vagina. She denies any significant urinary or bowel problems. On performance of a physical examination, you note that the cervix is just inside the level of the introitus. Based on the physical examination, which of the following is the most likely diagnosis? A. Normal examination B. First-degree uterine prolapse C. Second-degree uterine prolapse D. Third-degree uterine prolapse E. Complete procidentia

Answer 72

C. Second-degree uterine prolapse

Question 73

What is the most appropriate rate of use effectiveness (percentage of pregnancies per year of actual patient use) for the rhythm method? A. 80% B. 40% C. 15% to 25% D. 5% to 15% E. 3% to 10%

Answer 73

B. 40%

Question 74

A 25-year-old woman presents to you for routine well-woman examination. She has had two normal vaginal deliveries and is healthy. She smokes one pack of cigarettes per day. She has no gynecologic complaints. Her last menstrual period was 3 weeks ago. During the pelvic examination, you notice that her left ovary is enlarged to 5 cm in diameter. Which of the following is the best recommendation to this patient? A. Order CA-125 testing B. Schedule outpatient diagnostic laparoscopy C. Return to the office in 1 to 2 months to recheck the ovaries D. Schedule a CT scan of the pelvis E. Admit to the hospital for exploratory laparotomy

Answer 74

C. Return to the office in 1 to 2 months to recheck the ovaries

Question 75

A 32-year-old morbidly obese diabetic woman presents to your office complaining of prolonged vaginal bleeding. She has never been pregnant. Her periods were regular, monthly, and light until 2 years ago. At that time she started having periods every 3 to 6 months. Her last normal period was 5 months ago. She started having vaginal bleeding again 3 weeks ago, light at first. For the past week she has been bleeding heavily and passing large clots. On pelvic examination, the external genitalia is normal. The vagina is filled with large clots. A large clot is seen protruding through the cervix. The uterus is in the upper limit of normal size. The ovaries are normal to palpation. Her urine pregnancy test is negative. Which of the following is the most likely diagnosis? A. Uterine fibroids B. Cervical polyp C. Incomplete abortion D. Chronic anovulation E. Coagulation defect

Answer 75

D. Chronic anovulation

Question 76

During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed. Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient? A. Stress B. Primary hyperthyroidism C. Anorexia nervosa D. Congenital adrenal hyperplasia E. Polycystic ovarian disease

Answer 76

A. Stress

Question 77

A 30-year-old woman presents to your office for her well-woman examination and contraception. She has two prior vaginal deliveries without any complications. Her medical and surgical histories are negative. Her family history is significant for coronary heart disease in her father and breast cancer in her mother diagnosed at the age of 62 years. In addition to effective contraception, health benefits for women taking oral combination contraceptives include which of the following? A. Decreased risk of lung cancer B. Decreased incidence of benign breast disease C. Decreased diastolic hypertension D. Decreased risk of cervical cancer E. Decreased incidence of thromboembolism

Answer 77

B. Decreased incidence of benign breast disease

Question 78

A 39-year-old G3P3 complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with **no adnexal tenderness**. Results of endometrial biopsy are normal. Which of the following is the most likely diagnosis? A. Endometriosis B. Endometritis C. Adenomyosis D. Uterine sarcoma E. Leiomyoma

Answer 78

C. Adenomyosis

Question 79

A 56-year-old postmenopausal female presents complaining of vaginal bleeding. Her uterus is slightly enlarged and she has a 6-cm right adnexal mass. Endometrial biopsy shows adenocarcinoma of the endometrium. What is the ovarian tumor that is most likely to be associated with this clinical picture? A. Granulosa tumor B. Sertoli-Leydig cell tumor C. Immature teratoma D. Gonadoblastoma E. Krukenberg tumor

Answer 79

A. Granulosa tumor

Question 80

A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Which of the following classes of medication is a possible cause of her condition? A. Antiestrogens B. Gonadotropins C. Phenothiazines D. Prostaglandins E. GnRH analogues

Answer 80

C. Phenothiazines

Question 81

During your evaluation of a sexual assault victim in the emergency department, she expresses her fear of becoming pregnant due to the attack. Which of the following is the best method to recommend for emergency contraception? A. None, because it will cause an abortion and is morally wrong. B. None, because it will be ineffective if taken more than 12 hours after coitus. C. An intrauterine device, because it is 99% effective D. High-dose oral contraceptive pills E. Endometrial aspiration

Answer 81

D. High-dose oral contraceptive pills

Question 82

A 22-year-old woman presents to your office for her well-woman examination and contraception. She has no medical problems or prior surgeries. She does not smoke or drink. Her vital signs and physical examination are normal. You explain the risks and benefits of combination oral contraceptive pills to the patient. She wants to know how they will keep her from getting pregnant. Which of the following mechanisms best explains the contraceptive effect of birth control pills that contain both synthetic estrogen and progestin? A. Direct inhibition of oocyte maturation B. Inhibition of ovulation C. Production of uterine secretions that are toxic to developing embryos D. Impairment of implantation hyperplastic changes of the endometrium E. Impairment of sperm transport caused by uterotubal obstruction

Answer 82

B. Inhibition of ovulation

Question 83

You are an intern working the night shift in the emergency department. During the evaluation of a sexual assault victim, your attending physician asks you to order the appropriate laboratory tests. Which of the following tests should be ordered? A. HIV, HBsAg, Pap smear, RPR, and urine culture B. HIV, HBsAg, Pap smear, RPR, and urine pregnancy test C. Chlamydia and gonorrhea cultures, complete blood count, HIV, HBsAg, Pap smear, and RPR D. Chlamydia and gonorrhea cultures, HIV, HBsAg, Pap smear, RPR, and urine pregnancy test E. Chlamydia and gonorrhea cultures, HIV, HBsAg, RPR, urine culture, and urine pregnancy test

Answer 83

E. Chlamydia and gonorrhea cultures, HIV, HBsAg, RPR, urine culture, and urine pregnancy test

Question 84

An 86-year-old woman presents to your office for her well-woman examination. She has no complaints. On pelvic examination performed in the supine and upright positions, the patient has **second-degree prolapse of the uterus.** Which of the following is the best next step in the management of this patient? A. Reassurance B. Placement of a pessary C. Vaginal hysterectomy D. Le Fort procedure E. Anterior colporrhaphy

Answer 84

A. Reassurance

Question 85

A 29-year-old GO comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. Which of the following is the most likely diagnosis? A. Candidiasis B. Bacterial vaginosis C. Trichomoniasis D. Physiologic discharge E. Chlamydia

Answer 85

B. Bacterial vaginosis

Question 86

A 36-year-old woman drops by your office unexpectedly and wants to be seen for chronic pelvic pain. She has seen you in the past for well- woman examinations and has been treated for chlamydia. She smokes and drinks socially. She has no medical problems or prior surgeries. During questioning her about her chief complaint, she reveals that she was sexually assaulted last night at a club after having drinks with some girlfriends. You attempt to take detailed history of the assault; however, the woman's memory seems cloudy and inconsistent. Her physical examination is unremarkable. The victim's inability to think clearly and remember things is best explained by which of the following? A. Alcohol use B. Head injury C. Illicit drug use D. Rape trauma syndrome E. Secondary gain

Answer 86

D. Rape trauma syndrome

Question 87

A 28-year-old G3P0 has a history of severe menstrual cramps, prolonged, heavy periods, chronic pelvic pain, and painful intercourse. All of her pregnancies were spontaneous abortions in the first trimester. A hysterosalpingogram (HSG) she just had as part of the evaluation for recurrent abortion showed a large uterine septum. You have recommended surgical repair of the uterus. Of the patient's symptoms, which is most likely to be corrected by resection of the uterine septum? A. Habitual abortion B. Dysmenorrhea C. Menometrorrhagia D. Dyspareunia E. Chronic pelvic pain

Answer 87

A. Habitual abortion

Question 88

A patient forgets her oral contraceptive pill for 3 continuous days. What is the most appropriate response? A. Stop pills and resume after 7 days. B. Continue pills as usual. C. Continue pills and use an additional form of contraception. D. Take an additional pill. E. Stop pills and seek a medical examination.

Answer 88

C. Continue pills and use an additional form of contraception.

Question 89

An obese 46-year-old G6P1051 with type 1 diabetes since age 12 presents to your office complaining of urinary incontinence. She has been menopausal since age 44. Her diabetes has been poorly controlled for years because of her noncompliance with insulin therapy. She often cannot tell when her bladder is full, and she will urinate on herself without warning. Which of the following factors in this patient's history has contributed the most to the development of her urinary incontinence? A. Menopause B. Obesity C. Obstetric history D. Age E. Diabetic status

Answer 89

E. Diabetic status

Question 90

A 21-year-old GO presents to your office because her menses is 2 weeks late. She states that she is taking her birth control pills correctly; she may have missed a day at the beginning of the pack, but took it as soon at she remembered. She denies any medical problems, but 3 or 4 weeks ago she had a "viral stomach flu" and missed 2 days of work for nausea, vomiting, and diarrhea. Her cycles are usually regular even without contraceptive pills. She has been on the pill for 5 years and recently developed some midcycle bleeding, which usually lasts about 2 days. She has been sexually active with the same partner for the past 3 months and has a history of chlamydia 3 years ago. She has had a total of 10 sexual partners. A urine pregnancy test is positive. Which of the following is the major cause of unplanned pregnancies in women using oral contraceptives? A. Breakthrough ovulation at midcycle B. High frequency of intercourse C. Incorrect use of oral contraceptives D. Gastrointestinal malabsorption E. Development of antibodies

Answer 90

C. Incorrect use of oral contraceptives

Question 91

A 20-year-old GO, LMP 1 week ago, presents to your gynecology clinic complaining of a mass in her left breast that she discovered during routine breast self-examination in the shower. When you perform a breast examination on her, you palpate a 2-cm firm, nontender mass in the upper inner quadrant of the left breast that is smooth, well-circumscribed, and mobile. You do not detect any skin changes, nipple discharge, or axillary lymphadenopathy. Which of the following is the most likely diagnosis? A. Fibrocystic breast change B. Fibroadenoma C. Breast carcinoma D. Fat necrosis E. Cystosarcoma phyllodes

Answer 91

B. Fibroadenoma

Question 92

A 9-year-old girl has breast and pubic hair development. Evaluation demonstrates a pubertal response to a GnRH-stimulation test and a prominent increase in luteinizing hormone (LH) pulses during sleep. These findings are characteristic of patients with which of the following? A. Theca cell tumors B. latrogenic sexual precocity C. Premature thelarche D. Granulosa cell tumors E. Constitutional precocious puberty

Answer 92

E. Constitutional precocious puberty

Question 93

A 30-year-woman presents to your office with the fear of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer. You discuss with her the risks factors and prevention for ovarian cancer. Which of the following can decrease a woman's risk of ovarian cancer? A. Use of combination oral contraceptive therapy B. Menopause after age 55 C. Nonsteroidal anti-inflammatory drugs D. Nulliparity E. Ovulation induction medications

Answer 93

A. Use of combination oral contraceptive therapy

Question 94

What is the most common side effect of bleomycin? A. Hemorrhagic cystitis B. Renal failure C. Tympanic membrane fibrosis D. Necrotizing enterocolitis E. Pulmonary fibrosis F. Pancreatic failure G. Ocular degeneration H. Cardiac toxicity I. Peripheral neuropathy J. Bone marrow depression

Answer 94

E. Pulmonary fibrosis

Question 95

You are seeing a 37-year-old woman in your office for follow-up of an injury related to domestic violence. She states that her husband is over with his abusive behavior and is treating her like royalty. He has bought her a new necklace to show how sorry he is about the incident. She has changed her plans to seek counseling and to move out. Which of the following is the most likely outcome in this situation? A. Abuser accepts responsibility for his behavior. B. Cessation of all abuse. C. Decreased episodes of violence. D. Increasing severity of battering. E. Role reversal with victim taking control of relationship.

Answer 95

D. Increasing severity of battering.

Question 96

A 32-year-old female presents for her yearly examination. She has been smoking one pack of cigarettes a day for the past 12 years. She wants to stop, and you make some recommendations to her. Which of the following is true regarding smoking cessation in women? A. Ninety percent of those who stop smoking relapse within 3 months. B. Nicotine replacement in the form of chewing gum or transdermal patches has not been shown to be effective in smoking cessation programs. C. Smokers do not benefit from repeated warnings from their doctor to stop smoking. D. Stopping cold turkey is the only way to successfully achieve smoking cessation. E. No matter how long one has been smoking, smoking cessation appears to improve the health of the lungs.

Answer 96

E. No matter how long one has been smoking, smoking cessation appears to improve the health of the lungs.

Question 97

A 53-year-old postmenopausal woman, G3P3, presents for evaluation of troublesome urinary leakage 6 weeks in duration. Which of the following is the most appropriate first step in this patient's evaluation? A. Urinalysis and culture B. Urethral pressure profiles C. Intravenous pyelogram D. Cystourethrogram E. Urethrocystoscopy

Answer 97

A. Urinalysis and culture

Question 98

A 38-year-old woman presents to your office complaining of urinary incontinence. Her symptoms are suggestive of urge incontinence. She admits to drinking several large glasses of iced tea and water on a daily basis because her mother always told her to drink lots of liquids to lower her risk of bladder infections. Urinalysis and urine culture are negative. After confirming the diagnosis with physical examination and office cystometrics, which of the following treatments should you recommend to the patient as the next step in the management of her problem? A. Instruct her to start performing Kegel exercises. B. Tell her to hold her urine for 6 hours at a time to enlarge her bladder capacity. C. Instruct her to eliminate excess water and caffeine from her daily fluid intake. D. Prescribe an anticholinergic. E. Schedule cystoscopy.

Answer 98

C. Instruct her to eliminate excess water and caffeine from her daily fluid intake.

Question 99

An 18-year-old GO comes to see you complaining of a 3-day history of urinary frequency, urgency, and dysuria. She panicked this morning when she noticed the presence of bright red blood in her urine. She also reports some midline lower abdominal discomfort. She had intercourse for the first time 5 days ago and reports that she used condoms. On physical examination, there are no lacerations of the external genitalia, there is no discharge from the cervix or in the vagina, and the cervix appears normal. Bimanual examination is normal except for mild suprapubic tenderness. There is no flank tenderness, and the patient's temperature is normal. Which of the following is the most likely diagnosis? A. Chlamydia cervicitis B. Pyelonephritis C. Acute cystitis D. Acute appendicitis E. Monilial vaginitis

Answer 99

C. Acute cystitis

Question 100

A 45-year-old woman who had two normal pregnancies 15 and 18 years ago presents with the complaint of amenorrhea for 7 months. She expresses the desire to become pregnant again. After exclusion of pregnancy, which of the following tests is next indicated in the evaluation of this patient's amenorrhea? A. Hysterosalpingogram B. Endometrial biopsy C. Thyroid function tests D. Testosterone and DHAS levels E. LH and FSH levels

Answer 100

E. LH and FSH levels

Question 101

A 19-year-old patient presents to your office with primary amenorrhea. She has normal breast and pubic hair development, but the uterus and vagina are absent. Diagnostic possibilities include which of the following? A. XYY syndrome B. Gonadal dysgenesis C. Müllerian agenesis D. Klinefelter syndrome E. Turner syndrome

Answer 101

C. Müllerian agenesis

Question 102

A 55-year-old woman presents to your office for consultation regarding her symptoms of menopause. She stopped having periods 8 months ago and is having severe hot flushes. The hot flushes are causing her considerable stress. What should you tell her regarding the psychological symptoms of the climacteric? A. They are not related to her changing levels of estrogen and progesterone. B. They commonly include insomnia, irritability, frustration, and malaise. C. They are related to a drop in gonadotropin levels. D. They are not affected by environmental factors. E. They are primarily a reaction to the cessation of menstrual flow.

Answer 102

B. They commonly include insomnia, irritability, frustration, and malaise.

Question 103

You are seeing a patient in the emergency room who complains of fever, chills, flank pain, and blood in her urine. She has had severe nausea and started vomiting after the fever developed. She was diagnosed with a urinary tract infection 3 days ago by her primary care physician. The patient never took the antibiotics that she was prescribed because her symptoms improved after she started drinking cranberry juice. The patient has a temperature of 38.8°C (102°F). She has severe right-sided CVA tenderness. She has severe suprapubic tenderness. Her clean-catch urinalysis shows a large amount of ketones, RBCs, WBCs, bacteria, and squamous cells. Which of the following is the most appropriate next step in the management of this patient? A. Tell her to take the oral antibiotics that she was prescribed and give her a prescription of Phenergan rectal suppositories. B. Admit the patient for IV fluids and IV antibiotics. C. Admit the patient for diagnostic laparoscopy. D. Admit the patient for an intravenous pyelogram and consultation with a urologist. E. Arrange for a home health agency to go to the patient's home to administer IV fluids and oral antibiotics.

Answer 103

B. Admit the patient for IV fluids and IV antibiotics.

Question 104

A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. Which of the following is the most common cause of this condition in girls? A. Idiopathic B. Gonadal tumors C. McCune-Albright syndrome D. Hypothyroidism E. Tumors of the central nervous system

Answer 104

A. Idiopathic

Question 105

A 19-year-old woman is undergoing exploratory laparotomy for a 9-cm right ovarian mass. The final pathology report shows evidence of glial tissue and immature cerebellar and cortical tissue. What is the ovarian tumor that is most likely to be associated with this clinical picture? A. Granulosa tumor B. Sertoli-Leydig cell tumor C. Immature teratoma D. Gonadoblastoma E. Krukenberg tumor

Answer 105

C. Immature teratoma

Question 106

She feels this way because her daughter has been acting flirtatious around boys and also because she noted some bloody discharge on her daughter's underwear. The child lives at home with her mother, 1-year-old brother, maternal aunt, and 18-year-old cousin. The child's father is dead and mother is not seeing anyone currently. Which of the following is the most likely abuser? A. Male stranger B. Female stranger C. Male relative D. Female relative

Answer 106

C. Male relative

Question 107

You are called to the emergency department to evaluate a 23-year-old G1 who is 6 weeks pregnant and has vaginal bleeding. You have seen her in your office before for her well-woman examination. You had assisted her in receiving counseling and assistance for relationship problems with her verbally abusive boyfriend. She states that they are now married and their relationship has improved. You make the diagnosis of a threatened abortion in the emergency department and schedule the patient for an OB visit at your office in 2 weeks. Which of the following is the normal course of an abusive relationship during pregnancy? A. Abuse is uncommon during pregnancy. B. An increase in abuse occurs in about 20% of relationships. C. Abuse is usually directed away from the breast and abdomen. D. Pregnant women who are abused usually have fewer complaints. E. Abused women usually receive adequate prenatal care.

Answer 107

B. An increase in abuse occurs in about 20% of relationships.

Question 108

A 42-year-old G4P3104 presents for her well-woman examination. She has had three vaginal deliveries and one cesarean delivery for breech. She states her cycles are regular and denies any sexually transmitted diseases. Currently she and her husband use condoms, but they hate the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. She drinks and smokes socially. She weighs 78 kg, and her blood pressure is 142/89 mm Hg. During her office visit, you counsel the patient at length regarding birth control methods. Which of the following is the most appropriate contraceptive method for this patient? A. Intrauterine device B. Bilateral tubal ligation C. Combination oral contraceptives D. Diaphragm E. Transdermal patch

Answer 108

A. Intrauterine device

Question 109

Which type of sexual precocity is defined by the presence of virilizing signs in girls? A. True sexual precocity B. Incomplete sexual precocity C. Isosexual precocious pseudopuberty D. Heterosexual precocious pseudopuberty E. Precocity caused by gonadotropin-producing tumors

Answer 109

D. Heterosexual precocious pseudopuberty

Question 110

You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked. Which is the best day of the menstrual cycle to check her progesterone level if you are trying to confirm ovulation? A. Day 3 B. Day 8 C. Day 14 D. Day 21 E. Day 26

Answer 110

D. Day 21

Question 111

A 45-year-old woman with previously documented urge incontinence continues to be symptomatic after following your advice for conservative self-treatment. Which of the following is the best next step in management? A. Prescribe Ditropan (oxybutynin chloride). B. Prescribe Estrogen therapy. C. Schedule a retropubic suspension of the bladder neck. D. Refer her to a urologist for urethral dilation. E. Schedule a voiding cystourethrogram.

Answer 111

A. Prescribe Ditropan (oxybutynin chloride).

Question 112

A patient experiences no menses in the 7 days following a 21-day cycle of correct use of oral contraceptive pills. What is the most appropriate response? A. Stop pills and resume after 7 days. B. Continue pills as usual. C. Continue pills and use an additional form of contraception. D. Take an additional pill. E. Stop pills and seek a medical examination.

Answer 112

B. Continue pills as usual.

Question 113

A 36-year-old woman presents to your office for contraception. She has had three vaginal deliveries without complications. Her medical history is significant for hypertension, well-controlled with a diuretic, and a seizure disorder. Her last seizure was 12 years ago. Currently she does not take any antiepileptic medications. She also complains of stress-related headaches that are relieved with an over-the-counter pain medication. She denies any history of surgeries. She is divorced, smokes one pack of cigarettes per day, and has three to four alcoholic drinks per week. On examination, her vital signs include weight 90 kg, blood pressure 126/80 mm Hg, pulse 68 beats per minute, respiratory rate 16 breaths per minute, and temperature 36.4°C (97.6°F). Her examination is normal except for some lower extremity nontender varicosities. She has taken birth control pills in the past and wants to restart them because they help with her cramps. Which of the following would contradict the use of combination oral contraceptive pills in this patient? A. Varicose veins B. Tension headache C. Seizure disorders D. Smoking in a woman over 35 years of age E. Mild essential hypertension

Answer 113

D. Smoking in a woman over 35 years of age

Question 114

A patient experiences nausea during first cycle of oral contraceptive pills. What is the most appropriate response? A. Stop pills and resume after 7 days. B. Continue pills as usual. C. Continue pills and use an additional form of contraception. D. Take an additional pill. E. Stop pills and seek a medical examination.

Answer 114

B. Continue pills as usual.

Question 115

What is the most common side effect of doxorubicin? A. Hemorrhagic cystitis B. Renal failure C. Tympanic membrane fibrosis D. Necrotizing enterocolitis E. Pulmonary fibrosis F. Pancreatic failure G. Ocular degeneration H. Cardiac toxicity I. Peripheral neuropathy J. Bone marrow depression

Answer 115

H. Cardiac toxicity

Question 116

You have a 32-year-old G1P0 patient who has undergone a routine obstetrical ultrasound screening at 20 weeks of gestation. The patient phones you immediately following the ultrasound because during the procedure the ultrasonographer commented that she noted several small fibroid tumors in the patient's uterus. As this is the patient's first pregnancy, she is concerned regarding the possible effects that the fibroid tumors may have on the outcome of her pregnancy. As her obstetrician, which of the following should you tell her? A. Enlargement of the fibroids with subsequent necrosis and degeneration during pregnancy is common. B. Many women have fibroid tumors, but most fibroids are asymptomatic during pregnancy. C. Progression to leiomyosarcoma is more common in pregnancy attributed to the hormonal effects of the pregnancy. D. Preterm labor occurs frequently, even in women with asymptomatic fibroid tumors. E. She will have to have a cesarean delivery because the fibroid tumors will obstruct the birth canal.

Answer 116

B. Many women have fibroid tumors, but most fibroids are asymptomatic during pregnancy.

Question 117

A 28-year-old woman presents to your office with symptoms of a urinary tract infection. This is her second infection in 2 months. You treated the last infection with Bactrim DS for 3 days. Her symptoms never really improved. Now she has worsening lower abdominal discomfort, dysuria, and frequency. She has had no fever or flank pain. Physical examination shows only mild suprapubic tenderness. Which of the following is the best next step in the evaluation of this patient? A. Urine culture B. Intravenous pyelogram C. Cystoscopy D. Wet smear E. CT scan of the abdomen with contrast

Answer 117

A. Urine culture

Question 118

What method of contraception is medically contraindicated for a woman with a history of deep vein thrombosis? A. Oral contraceptives B. IUD C. Condoms D. Laparoscopic tubal ligation E. Diaphragm

Answer 118

A. Oral contraceptives

Question 119

A 20-year-old woman presents to your office with the complaint of abdominal pain. Through further questioning, the woman reveals that she was sexually assaulted at a party 3 weeks ago by a male friend whom she recently started dating. She states that she has not revealed this to anyone else and has not informed the police because she was drinking. Her abdominal and pelvic examinations are normal. Which of the following is the best management to offer this patient? A. Counsel patient to sue male friend. B. Provide an antidepressant. C. Provide emergency contraception. D. Test for and treat sexually transmitted infections. E. Order CT of the abdomen and pelvis.

Answer 119

D. Test for and treat sexually transmitted infections.

Question 120

You are evaluating a 36-year-old female in the emergency department for a broken arm. She states that she slipped in the tub. This is the third time you have seen her for a trauma-related injury in the past 6 months. You suspect domestic violence. After treating her broken arm and evaluating her emotional status, which of the following is the next appropriate step in the management of this patient? A. Confront the patient's partner. B. Discharge her to home. C. Offer counseling and resources. D. Order her to leave her partner. E. Provide an antidepressant.

Answer 120

C. Offer counseling and resources.

Question 121

A 22-year-old nulliparous woman has recently become sexually active. She consults you because of painful coitus, with the pain located at the vaginal introitus. It is accompanied by painful involuntary contraction of the pelvic muscles. Other than confirmation of these findings, the pelvic examination is normal. Which of the following is the most common cause of this condition? A. Endometriosis B. Psychogenic causes C. Bartholin gland abscess D. Vulvar atrophy E. Ovarian cyst

Answer 121

B. Psychogenic causes

Question 122

You are a chief resident at a university hospital and are called down to the emergency room at 5:00 AM on a Saturday to evaluate an 18-year-old undergraduate, who presented to the emergency room complaining of being a victim of sexual assault while attending a fraternity party the evening before. When you first encounter this patient to take a detailed history, she remains very calm but has trouble remembering the details of the experience. She denies any ingestion of any alcohol or illicit drugs. Which of the following is most likely a component of the acute phase of the rape trauma syndrome? A. No physical complaints. B. Duration for up to 6 months after the event. C. Always in control of emotions. D. The reaction of the victim may be influenced by victim's relationship to the attacker. E. The victim's coping mechanisms usually remain intact.

Answer 122

D. The reaction of the victim may be influenced by victim's relationship to the attacker.

Question 123

A patient in your practice calls you in a panic because her 14-year-old daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5 ft 4 in tall and weighs 95 Ib. Which of the following blood tests is not indicated in the evaluation of this patient? A. BHCG B. Bleeding time C. CBC D. Type and screen E. Estradiol level

Answer 123

E. Estradiol level

Question 124

A mother brings in her 16-year-old daughter for an evaluation of chronic abdominal pain. You have seen the girl many times before for various vague complaints over the past year. She has regular cycles that last 4 days with medium to light flow. She denies dysmenorrhea, gastrointestinal symptoms, or feeling depressed. She denies any sexual activity. The mother states that lately she has been doing poorly in school. She denies drug or alcohol use. Her mother thinks it may be related to recent changes at home since the mother's boyfriend moved in. Your examination and laboratory tests are normal. A previous workup by a gastroenterologist was also negative. Which of the following is the best next step in the management of this patient's symptoms? A. Initiate biofeedback therapy for chronic pain. B. Order immediate psychiatric evaluation. C. Prescribe antibiotic for chronic gastroenteritis. D. Prescribe antidepressant. E. Question the patient about possible sexual abuse.

Answer 124

E. Question the patient about possible sexual abuse.

Question 125

A mother brings her daughter in to see you for consultation. The daughter is 17 years old and has not started her period. She is 4 ft 10 in tall. She has no breast budding. On pelvic examination, she has no pubic hair. By digital examination, the patient has a cervix and uterus. The ovaries are not palpable. As part of the workup, serum FSH and LH levels are drawn and both are high. Which of the following is the most likely reason for delayed puberty and sexual infantilism in this patient? A. Adrenogenital syndrome (testicular feminization) B. McCune-Albright syndrome C. Kallmann syndrome D. Gonadal dysgenesis E. Müllerian agenesis

Answer 125

D. Gonadal dysgenesis

Question 126

You have diagnosed a healthy, sexually active 24-year-old female patient with an uncomplicated acute urinary tract infection. Which of the following is the likely organism responsible for this patient's infection? A. Chlamydia B. Pseudomonas C. Klebsiella D. Escherichia coli E. Candida albicans

Answer 126

D. Escherichia coli

Question 127

Which of the following pubertal events in girls is not estrogen dependent? A. Menses B. Vaginal cornification C. Hair growth D. Reaching adult height E. Production of cervical mucus

Answer 127

C. Hair growth

Question 128

What method of contraception is medically contraindicated for a woman with a known latex allergy? A. Oral contraceptives B. JUD C. Condoms D. Laparoscopic tubal ligation E. Diaphragm

Answer 128

C. Condoms

Question 129

An 18-year-old college student, who has recently become sexually active, is seen for severe primary dysmenorrhea. She does not want to get pregnant, and has failed to obtain resolution with heating pads and mild analgesics. Which of the following medications is most appropriate for this patient? A. Prostaglandin inhibitors B. Narcotic analgesics C. Oxytocin D. Oral contraceptives E. Luteal progesterone

Answer 129

D. Oral contraceptives

Question 130

A 28 year old G3P3 presents to your office for contraceptive counseling. She denies any medical problems or sexually transmitted diseases. You counsel her on the risks and benefits of all contraceptive methods. Which of the following is the most common form of contraception used by reproductive-age women in the United States? a. Pills b. Permanent sterilization c. Intrauterine device (IUD) d. Diaphragm

Answer 130

b. Permanent sterilization

Question 131

You are doing postpartum rounds on a 22-year-old G1P1, who vaginally delivered an infant male at 36 weeks after an induction for severe nreec amnsia. Durino her anor she renuired nvdra azine to control ner blood pressures. She is on magnesium sulfate for seizure prophylaxis. Her vital sions are: blood pressure 134/98 mm Me. ouse 95 beats ver minute. respiratory rate 24 breaths per minute, and temperature 37.3°C. She has adequate urine output at greater than 40 cc/h. On examination, she is oriented to time and place, but she is somnolent and her speech is slurred. She has good movement and strength of her extremities, but her deep tendon reflexes are absent. Which of the following is the most likely cause of her symptoms? a. Magnesium toxicity

Answer 131

a. Magnesium toxicity

Question 132

A 28-year-old G3P3 presents to your office for contraceptive counseling. She denies any medical problems or sexually transmitted diseases. You counsel her on the risks and benefits of all contraceptive methods. Which of the following is the most common form of contraception used by reproductive-age women in the United States? A. Pills B. Condom C. Diaphragm D. Intrauterine device (IUD) E. Permanent sterilization

Answer 132

E. Permanent sterilization