Gyneco 1-140 GD

1. A 29-year-old Caucasian primigravida patient is 20 weeks pregnant with twins. She found out today on her routine ultrasound for fetal anatomy that she is carrying two boys. In this patient’s case, which of the following statements about twinning is true?

2. 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?

3. After delivery of a term infant with Apgar scores of 2 at 1 minute and 7 at 5 minutes, you ask that umbilical cord blood be collected for pH. The umbilical arteries carry which of the following?

During the routine examination of the umbilical cord and placenta after a spontaneous vaginal delivery, you notice that the baby had only one umbilical artery. Which of the following is true regarding the finding of a single umbilical artery?

A 22-year-old G1P0 at 28 weeks gestation by LMP presents to labor and delivery complaining of decreased fetal movement. She has had no prenatal care. On the fetal monitor there are no contractions. The fetal heart rate is 150 beats per minute and reactive. There are no decelerations in the fetal heart tracing. An ultrasound is performed in the radiology department and shows a 28-week fetus with normal-appearing anatomy and size consistent with dates. The placenta is implanted on the posterior uterine wall and its margin is well away from the cervix. A succenturiate lobe of the placenta is seen implanted low on the anterior wall of the uterus. Doppler flow studies indicate a blood vessel is traversing the cervix connecting the two lobes. This patient is most at risk for which of the following?

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?

7. A 22-year-old primigravida presents to your office for a routine OB visit at 34 weeks gestational age. She voices concern because she has noticed an increasing number of spidery veins appearing on her face, upper chest, and arms. She is upset with the unsightly appearance of these veins and wants to know what you recommend to get rid of them. Which of the following is the best advice to give this patient?

A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 hours. The patient also admits to bouts of nausea and emesis since eating a very spicy meal at a new Thai restaurant the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor who examines her pages you and reports that the patient has a low-grade fever of 37.7C (100F), with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds. She has no rebound tenderness. The patient has a WBC of 13,000, and electrolytes are normal. Which of the following is the most appropriate next step in the management of this patient?

A healthy 34-year-old G1P0 patient comes to see you in your office for a routine OB visit at 12 weeks gestational age. She tells you that she has stopped taking her prenatal vitamins with iron supplements because they make her sick and she has trouble remembering to take a pill every day. A review of her prenatal labs reveals that her hematocrit is 39%. Which of the following statements is the best way to counsel this patient?

10. 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?

11. A 14-year-old G1P0 girl who is 29 weeks’ pregnant with twins presents to the emergency department following a seizure. She was watching television and stood up to go to the bathroom when she “fell down and started shaking.” The patient has no history of seizures and is otherwise healthy. She missed her last obstetrician’s appointment, and her aunt states that her niece has had a lot of headaches and swelling over the past 2 days. On examination the patient is somnolent and difficult to arouse, and has edema of her hands and face. Her blood pressure is 205/120 mm Hg, pulse is 80/ min, and respiratory rate is 16/min. The fetal heart rate is 130/min. Which of the following is the most correct advice for the patient’s aunt?

12. A 19-year-old woman at 32 weeks’ gestation was the driver in a front-end motor vehicle crash. The air bags did not inflate, and the patient sustained blunt trauma to the abdomen. The patient is taken to a nearby emergency department in stable condition, where she notes a small amount of bright red blood on her underwear. Maternal vital signs are significant for a heart rate of 110/min and blood pressure of 110/55 mm Hg. What is most appropriate next step in management?

13. A 19-year-old G1P0 woman presents to the emergency department in active labor and delivers a full-term male infant. The infant appears healthy with the exception of jaundice (bilirubin 10 mg/dL [>95th percentile]). The mother does not speak English, but a cousin who does states that he has seen the mother taking pills prescribed by her doctor, although he does not know the reason she was taking medication. Based on the newborn’s jaundice, which drug was the mother most likely taking?

14. A 16-year-old girl presents to the emergency department complaining of fever, chills, abdominal pain, and vaginal bleeding. She gives a history of unprotected sexual activity with her 17-year-old boyfriend over the past several months. Her last menstrual period was 8 weeks ago. She reports having a dilatation and curettage procedure at an unlicensed abortion clinic recently to try to abort the pregnancy. Her temperature is 38.7°C (101.7°F), heart rate is 120/min, and blood pressure is 100/70 mm Hg. Pelvic examination reveals cervical motion tenderness, tissue in the internal os, and foul-smelling vaginal discharge. Urine is positive for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

15. A 30-year-old obese G3P2 woman is in active labor at 41 weeks’ gestation. She has no significant past medical history, and had an uncomplicated pregnancy with appropriate prenatal evaluation. The patient ruptured membranes spontaneously 30 minutes ago. Contractions occur regularly every 2–3 minutes. Early decelerations are noted on the fetal heart rate monitor with each of the past five contractions. Which is the most appropriate next step in management?

16. A 25-year-old G2P1 woman who is 36 weeks pregnant presents to her obstetrician complaining of restlessness and weakness for the past month. She says her boyfriend recently left her and their 2-year-old son, and she feels overwhelmed with this pregnancy. She denies feeling depressed but does report that she has trouble sleeping. She had an upper respiratory infection last month, “caught from my son,” and states she still has a sore throat. Laboratory tests show: WBC count: 8000/mm³; Hemoglobin: 11.0 g/dL; Hematocrit: 40% Platelet count: 250,000/mm³; Thyroid-stimulating hormone: 0.5μU/mL; Free thyroxine: 4.0 ng/dL. Which of the following is the best next step in management?

17. A 19-year-old G0 woman presents to her family physician complaining of dysmenorrhea for the past year. She reports severe right-sided pain that coincides with days 1–5 of her menstrual cycle. Her menses occur regularly every 28 days, and she requires three to four pads per day for the first 2 days of her bleeding and one to two pads per day for the remainder. She has never had surgery. She is not sexually active and does not smoke. Her last menstrual period was 1 week ago. Her temperature is 36.7°C (98.1°F), blood pressure is 121/74 mm Hg, heart rate is 80/min, and respiratory rate is 14/min. Physical examination reveals a thin, healthy-appearing young woman. Pelvic examination reveals a normal sized uterus and no cervical motion tenderness. Which of the following is the most likely diagnosis?

18. A 36-year-old G1P0 woman pregnant with twins presents to her obstetrician for her routine 32-week appointment. She has gained 5.4kg (12-lb) in the past 2 weeks. When questioned about her weight gain, she states she has had headaches and some blurred vision for the past 2 weeks, which she thinks is secondary to dehydration. To circumvent this, she has been drinking a lot of water, which she claims “is making me swell, even my hands.” She also has had some epigastric pain for the past 2 weeks, which she attributes to “all the water I’ve been drinking.” Her blood pressure is 142/90 mm Hg, pulse is 105/min, and respiratory rate is 18/min. Urinalysis reveals 1+ glycosuria and 4+ proteinuria. Which of the following is the best next step in management?

19. A 27-year-old woman has used oral contraceptives (OCs) without problems for 5 years. However, she just read an article about complications of OCs in a popular women’s magazine and asks you about the risks and hazards of taking OCs. You correctly tell her which of the following?

20. After an appropriate diagnostic evaluation, a 59-year-old woman with postmenopausal bleeding had a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). The pathologic diagnosis is adenocarcinoma of the endometrium. An endometrial adenocarcinoma that is confined to the uterus and extends more than 50% through the myometrium is at which stage?

21. A 39-year-old woman at 16 weeks’ gestation complains of headaches, blurred vision, and epigastric pain. Her blood pressure is now 156/104 mmHg. Her uterine fundus is palpable 22 cm above her symphysis pubis. Fetal heart tones could not be heard with a handheld Doppler. She has 3+proteinuria. Which of the following is the most likely diagnosis?

22. A 23-year-old woman develops painful vulvar vesicles that contain intranuclear inclusions on cytologic examination. She is 22 weeks’ pregnant. Which of the following statements about genital herpes is correct?

23. A 63-year-old woman has a 3-cm pruritic lesion on her right labia majora that she has noted for approximately 9 months. She has been treated with various topical creams and ointments for vulvar candidiasis without resolution of her symptoms or lesion. When you examine this woman, the lesion is still present. Which of the following is the most appropriate intervention?

24. A 35-year-old G3P3 woman has been experiencing bilateral breast pain for the past year. Breast examination and mammography are normal. Conservative measures have failed. Which of the following medications is most likely to bring relief?

25. 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?

26. 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?

27. In an amenorrheic patient who has had pituitary ablation for a craniopharyngioma, which of the following regimens is most likely to result in an ovulatory cycle?

28. In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and β-hCG assays. The β-hCG test is positive, and the prolactin level is 100 ng/mL (normal is <25 ng/mL in nonpregnant women in this assay). This patient requires which of the following

29. A 23-year-old married woman consults you because she and her husband have never consummated their marriage because she has severe pain with attempts at vaginal penetration. Her pelvic examination is normal except for involuntary tightening of her vaginal muscles when you attempt to insert a speculum. Which of the following conditions would best be treated with the use of vaginal dilators?

30. A 24-year-old woman presents to the emergency department complaining of right lower quadrant pain and vaginal spotting. Her last menstrual period was 5 weeks ago. Her temperature is 37 C (98.6 F), blood pressure is 112/70 mm Hg, pulse is 74/min, and respirations are 14/min. The abdomen is soft and non-tender. Pelvic examination reveals scant blood in the vagina, a closed cervical os, no pelvic masses, and right pelvic tenderness. Her leukocyte count is 8000/mm3, hematocrit is 38%, and a platelet count is 250,000/mm3. Which of the following is the most appropriate step next in diagnosis?

31. A 35-year-old African American woman presents to a physician complaining of irregular menstrual periods. She had her first menses at age 15 and states that her periods come irregularly every 2 to 6 months. She has been in a monogamous relationship with her husband for 15 years; for 10 years they have been trying unsuccessfully to conceive. She gets yearly Pap smears, which have been normal. Her height is 5 feet 2 inches (157.5 cm), and her weight is 200 pounds (90.9 kg). Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 80/min, and respirations are 14/min. She has acne, as well as excess hair, on her face and between her breasts. Her abdomen is obese. Examination is otherwise within normal limits. This patient is at greatest risk for developing which of the following diseases?

32. A 32-year-old Hispanic woman presents to the emergency department complaining of heavy vaginal bleeding. Her temperature is 37 C (98.6 F), blood pressure is 80/50 mm Hg, pulse is 110/min, and respirations are 18/min. Her abdomen is soft, non-tender and non-distended. Her pelvic examination reveals approximately 200 mL of clotted blood in the vagina, an open cervical os with tissue protruding from it, and a 10-week-sized, non-tender uterus. Leukocyte count is 9000/mm3, hematocrit is 22%, and platelet count is 275,000/mm3. Quantitative hCG is 100,000mIU/L (normal: 5-200,000mIU/L). Pelvic ultrasound shows echogenic material within the uterine cavity consistent with blood or tissue, no adnexal masses, and no free fluid. No viable pregnancy is seen. Which of the following is the most appropriate next step in management?

33. A 25-year-old Caucasian woman, gravida 1, para 0, at 26 weeks' gestational age presents to her physician's office complaining of spotting from the vagina. She has no contractions and reports normal fetal movement. She denies any history of a bleeding disorder. Her temperature is 37.3 C (99.1 F), blood pressure is 100/60 mm Hg, pulse is 75/min, and respirations are 14/min. Her abdomen is gravid and benign, with a fundal height of 26 cm. A placenta previa is ruled out by ultrasound examination. Pelvic examination reveals some scant blood in the vagina, a closed os, and no uterine tenderness. Leukocyte count is 12,000/mm3, hematocrit is 33%, and platelet count is 140,000/mm3. Her blood type is A, Rh negative. Which of the following is the most appropriate pharmacotherapy?

34. A 29-year-old primigravid woman is admitted to the labor and delivery ward with strong contractions every 2 minutes and cervical change from 3 to 4 cm. Over the next 5 hours she progresses to full dilation. After 3 hours of pushing, the physician cuts a mediolateral episiotomy, and the woman delivers a 3770-g (8-lb, 4-oz) boy. Which of the following is the main advantage of a mediolateral episiotomy over a median (midline) episiotomy?

35. A 22-year-old woman presents with mouth sores, sore throat, vaginal discharge, fever, and myalgia. She has no other medical problems. She takes oral contraceptive pills. She is in a monogamous relationship and states that her partner occasionally uses barrier contraception. Physical examination reveals a temperature of 38.3 C (101 F), cervical and inguinal lymphadenopathy, exudative pharyngitis, and multiple ulcers on the oral mucosa, the labia, and cervix. The vaginal discharge is profuse, and Gram stain indicates many neutrophils. Which of the following is the most likely diagnosis?

36. A 34-year-old woman, gravida 3, para 2, at 38 weeks gestation presents to the labor and delivery ward complaining of headache. She has no contractions. Her prenatal course was unremarkable until she noted the onset of swelling in her face, hands, and feet this week. Her obstetric history is significant for two normal spontaneous vaginal deliveries. She has no significant past medical or surgical history. Her temperature is 37 C (98.6 F), blood pressure is 160/92 mm Hg, pulse is 78/min, and respirations are 16/min. Examination reveals 3+ patellar reflexes bilaterally. A cervical examination reveals that her cervix is 3 cm dilated and 50% effaced and soft, and that the fetus is at 0 station and vertex. The fetal heart rate has a baseline of 140/min and is reactive. The results from a 24-hour urine collection show 5200 mg of protein (normal <300 mg/24 hours). The patient is given magnesium sulfate intravenously for seizure prophylaxis. Which of the following is the most appropriate next step in the management of this patient?

37. A 14-year-old Caucasian female presents to clinic for a routine check -up. She complains that her menstrual cycles are irregular and that her menses last seven to ten days. She underwent menarche one year ago and her last menstrual period was two weeks ago. She eats a balanced diet and works out in a gym on weekends. Her past medical history is insignificant and her BMI is 25 kg/m2. Which of the following is the most likely cause of this patient's complaints?

38. An ovarian mass removed from a 49-year-old female has yellow coloration of its cut surface. The pathologist describes it as a granulosa-theca cell tumor. Based on this pathology report, the tumor is most likely to secrete:

39. A 32-year-old female with a history of amenorrhea develops white nipple discharge. She eats a balanced diet and exercises regularly. She is not sexually active. Her family history is significant for her mother dying of breast cancer at age 50. The most likely diagnosis in this patient is:

40. A 38-year-old Caucasian female presents to your office complaining of a small amount of vaginal discharge that appears following sexual intercourse. There is no associated abdominal pain or urinary symptoms. Her menstrual cycles occur with regular 28-day cycles; her last menstrual period was 2 weeks ago. She has never been pregnant. Menarche occurred at age 10, and she has been sexually active with 10 different partners over the last 20 years. She smokes two packs of cigarettes per day and consumes alcohol regularly. She admits that her diet is poor in vegetables and fruit. Her mother died of breast cancer at age 54, and her father, who is living, has hypertension. Cervical biopsy reveals cervical intraepithelial neoplasia Ill (CIN Ill). Which of the following is the strongest risk factor for this condition?