USMLE OBGYN MANAGEMENT P2 213 QCM

201) A 26-year-old woman, gravida 2, para 1 at 28 weeks' gestation, comes to the physician for a follow-up ultrasound after a previous ultrasound demonstrated a marginal placenta previa. The present ultrasound shows complete resolution of the marginal previa, but the fetus is noted to be in breech presentation. The patient has otherwise had an unremarkable prenatal course. She has no medical problems and has never had surgery. She takes prenatal vitamins and is allergic to sulfa drugs. Assuming that the fetus stays in breech presentation, when should an external cephalic version be attempted?

202) A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7 F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?

203) A 36-year-old woman, gravida 2, para 1, at 16 weeks' gestation undergoes amniocentesis for evaluation of Down syndrome. She has no past medical history. Immediately after the procedure she becomes breathless, cyanotic and loses consciousness. Minutes later, she experiences a generalized tonic-clonic seizure. A generalized purpuric rash is noted. Her blood pressure is 90/50 mm Hg, pulse is 110/min, and respirations are 26/min. Oxygen saturation is 75% on 100% facemask. Which of the following is the most appropriate next step in management?

204) A 23-year-old primigravid woman at 38 weeks gestation is admitted to the delivery room for management of labor. She has been in active labor for 4 hours, during which her cervical dilation has progressed from 3 cm to 8 cm and descent has progressed from the -1 to +1 station. Examination 6 hours later shows the same degree of dilation and descent. The fetal head is in the left occipitoanterior (LOA) position. An external tocometer reveals adequate contractions 3 minutes apart lasting 50 seconds each. Internal pelvic assessment reveals prominent ischial spines. Fetal heart monitoring shows a baseline of 140/min with frequent accelerations. Prenatal ultrasound at 37 weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?

205) A 19-year-old primigravid woman at 32 weeks gestation comes to the physician's office because of w eight gain and mild generalized body swelling. She has no previous medical problems and her pregnancy has been otherwise uncomplicated. Her blood pressure is 150/90 mm Hg. Physical examination show s mild generalized edema; the remainder of her examination is unremarkable. A fetal heart tracing is reassuring. Laboratory studies show: Hematocrit: 48%, Platelets: 230,000/mm3, Serum creatinine: 1.0 g/dl, Alanine aminotransferase: 35 U/L, Urinalysis: 2 +protein. Amniotic fluid analysis show s immature fetal lungs. She lives close to the hospital and is compliant with medication follow-ups. Which of the following is the most appropriate next step in management?

206) A nurse called to report a low grade temperature in a 20-year-old woman who delivered a healthy baby 12 hours earlier. She had a normal vaginal delivery, and the placenta was delivered spontaneously. She had shaking chills during and ten minutes following the delivery. She continues to have bloody vaginal discharge. Her temperature is 38.0 C (100.4 F), blood pressure is 120/80 mmHg, pulse is 76/min and respirations are 14/min. Pelvic examination shows bloody discharge along with small blood clots on the introitus and vaginal walls. Her uterus is firm and non-tender. Laboratory studies show a WBC of 11,000/mm3 with 78% neutrophils. Which of the following is the most appropriate next step in management?

207) A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 110/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50%, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mEq/L, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?

208) A 17-year-old female comes to your office for advice. She says that she is planning to have sexual intercourse with her boyfriend for the first time. However, she is worried about contracting a urinary tract infection because she has heard that there is a high incidence of UTI's in sexually-active females. Which of the following is the most appropriate advice to give this patient to decrease her chance of contracting a urinary tract infection

209) A 19-year-old woman comes to the emergency department because of a 2-day history of fever, shaking chills and lower abdominal pain. She had an abortion at an outside clinic 3 days ago. Her temperature is 39.8C (103.7F), blood pressure is 100/65mmHg, pulse is 114/min and respirations are 26/min. Physical examination shows mild rigidity and guarding. Fundal height is at 12 weeks gestation, the adnexae are free and no mass is noted. Bimanual examination shows uterine tenderness with purulent, offensive vaginal discharge coming out of a dilated cervical os. Which of the following is the most appropriate sequence in management?

210) A 28-year-old woman, gravida 2, para 0, aborta 1, at 30 weeks' gestation comes to the physician because of a decrease in fetal movements. She has felt no fetal movements the past 18-hours. Her prenatal course, prenatal tests, and fetal growth have been normal up to this point. Triple test was performed at 14-weeks and showed no abnormalities. Her first pregnancy was terminated because her fetus was diagnosed with Down's syndrome. She does not use tobacco, alcohol, or drugs. Fetal heart tones are heard by Doppler. Non-stress test is non-reactive; therefore, biophysical profile is performed and shows a score of 8. Which of the following is the most appropriate next step in management?

211) A 22-year-old woman consults you for treatment of hirsutism. She is obese and has facial acne and hirsutism on her face and periareolar regions and a male escutcheon. Serum LH level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHAS is normal. The patient does not wish to conceive at this time. Which of the following single agents is the most appropriate treatment of her condition?

212) 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?

213) A 27-year-old woman presents to your office complaining of mood swings, depression, irritability, and breast pain each month in the week prior to her menstrual period. She often calls in sick at work because she cannot function when she has the symptoms. Which of the following medications is the best option for treating the patient’s problem?

214) 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?

215) A 54-year-old Caucasian female is complaining of hot flashes, vaginal dryness and irritability. Her symptoms started about a year ago, and have been gradually getting worse. She has not had a menstrual period for 12 months. She currently smokes 1 pack of cigarettes daily and drinks a glass of wine occasionally. The cardiorespiratory examination is unremarkable. Inspection of her vagina reveals dryness and atrophy. She asks about the risks and benefits of combination hormone replacement therapy (HRT). Which of the following is NOT an appropriate statement to make regarding this treatment modality?

216) A 25-year-old woman at 28 weeks gestation comes to the ER because of strong, regular and painful uterine contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination shows pooling of amniotic fluid within the vagina, and a cervix that is 4cm dilated and 80% effaced. Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis in the fetus. Which of the following is the most appropriate next step in management?

217) A 16-year-old Caucasian female is brought to your office by her mother who is concerned that her daughter has not had menstrual bleedings yet. Her past medical history is significant for an episode of severe bilateral pneumonia that required hospitalization when she was seven years old. Physical examination reveals Tanner stage 3 breast development, but very little pubic and axillary hair. A left-sided inguinal mass is palpated. A blind vaginal pouch is noted on pelvic exam. A karyotype analysis showed 46 XY. Which of the following is the most appropriate next step in the management of this patient?

218) A 25-year-old woman is referred to the physician for lactation suppression after the death of her 1-month-old infant from severe sepsis. She is very depressed and complains of breast fullness and tenderness. Examination shows both breasts are warm, firm and tender to palpation. Prenatal records show no abnormalities except mild varicosities. Which of the following is the most appropriate next step in management?

219) A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are 14/min. Physical examination is unremarkable. Which of the following is the most appropriate therapy for this patient?

220) A 25-year-old female comes to the physician because of abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms seven to ten days before the start of each menstrual cycle. She has a past history of postpartum depression, but she denies any recent feelings of hopelessness or guilt. Physical examination shows no abnormalities. Complete blood count, serum chemistries and thyroid stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management?

221) A 23-year-old, gravida 2, para 1 woman at 30 weeks gestation comes to the ER after she noticed a sudden gush of clear fluid coming from her vagina. She has had no uterine contractions or vaginal bleeding. Her pregnancy has been uncomplicated; she has had consistent prenatal care. Vital signs are normal. Sterile speculum examination shows the cervix is minimally effaced and 2cm dilated; there is pooling of clear fluid in the vaginal fornix, and when pressure is applied to the fundus, clear fluid comes out of the cervix. Emergency ultrasound shows a fetus of average size in the vertex presentation and an Amniotic Fluid Index (AFI) of 15. Nonstress test shows a baseline of 120 bpm and frequent accelerations. Amniotic fluid analysis shows lecithin/sphingomyelin ratio of 1.0. Which of the following is the most appropriate next step in management?

222) A 93-year-old woman is sent to your office from the nursing home for evaluation of vaginal bleeding. She is a poor historian and history is provided by her caregiver. Per her caregiver, she has a history of cerebrovascular accident with residual weakness, myocardial infarction, hypertension, type 2 diabetes mellitus and chronic renal insufficiency. She has been wheelchair-bound and living in the nursing home since her stroke five years ago. She takes multiple medications. Her temperature is 37.2 C (98.9 F), blood pressure is 176/76, pulse is 74/min and respirations are 14/min. She is awake, alert, and oriented to person, place and time. Physical examination reveals a friable, bleeding vaginal mass 3cm in size, and a malodorous vaginal discharge. The remainder of the examination reveals left-sided spasticity and weakness. Biopsy of the mass reveals squamous cell carcinoma of the vagina, that does not extend to the pelvic wall. CT scan of the abdomen and pelvis shows no evidence of metastasis. You call the patient's daughter, who is the power of attorney, and she requests that you do the best you can. Which of the following is the most appropriate next step in management?

223) A 33-year-old woman is 12 weeks pregnant with her third pregnancy. Her prior two pregnancies were uncomplicated and resulted in two normal spontaneous vaginal deliveries. It has been 7 years since her last delivery, and 4 years ago she was diagnosed with chronic hypertension. She was managed on an ACE-inhibitor but discontinued all medication when she started trying to conceive 6 months ago. She is doing well during the pregnancy except for some mild nausea and rare vomiting. Her physical examination is within normal limits for a woman at 12 weeks’ gestation. Her current blood pressure is 100/60 mmHg. At which of the following blood pressures should antihypertensive therapy be initiated in this patient?

224) A 39-year-old woman, gravida 3, para 2, at 39 weeks’ gestation comes to the labor and delivery ward with regular contractions and gush of fluid 1 hour ago. On examination she is found to have rupture of membranes and is 4 cm dilated. She is admitted to labor and delivery. Her prenatal course was significant for a 36-week vaginal culture that was positive for Group B Streptococcus (GBS) that is sensitive to clindamycin. She also has gestational diabetes that is treated with diet. She has no other medical problems and has never had surgery. She takes no medications and is allergic to penicillin. After she is admitted to the labor and delivery ward, a penicillin infusion is erroneously started. Soon thereafter, the patient develops generalized pruritus and urticaria with angioedema and difficulty breathing. Which of the following is the most appropriate next step in the management of this patient?

225) An infertile couple presents to you for evaluation. A semen analysis from the husband is ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show normal morphology; 20% of the sperm show progressive forward mobility. You should tell the couple which of the following?

226) A 24-year-old woman has fever, right upper quadrant pain, and lower abdominal pain. She reports having multiple sexual partners and does not use condoms. She has no medical history, does not take any medications, and has no drug allergies. Her temperature is 38.9 C (102.0 F). Her lungs are clear to auscultation. Abdomen examination is notable for right upper quadrant tenderness. Pelvic examination reveals mucopurulent drainage and tenderness with cervical motion. She also has adnexal tenderness. Her leukocyte count is 14,000/mm3. Liver function tests are normal. Abdominal imaging is normal. Urine pregnancy test is negative. Which of the following is the appropriate management?

227) A 33-year-old woman comes to the clinic at 16 weeks’ gestation with no complaints. This is her second pregnancy. During the first pregnancy she delivered an 8.5 lb. infant. The patient reports hydramnios during that pregnancy. She has no prior medical history and is on no medications. On physical examination, she has a firm uterus. Which of the following is the appropriate management of this patient?

228) A 19-year-old G1P0 African American woman who is at 30 weeks’ gestation is admitted to the hospital from the obstetrics clinic after being found to have an elevated blood pressure during a routine prenatal visit. She complains of a constant headache, intermittent blurred vision, and episodic nausea and vomiting for the last week. Before this week her pregnancy has been uncomplicated, and her prenatal visits have not revealed any health problems. Vital signs are: blood pressure 180/110 mm Hg, pulse 110/min, respirations 26/min. She is afebrile. Physical examination reveals a systolic ejection murmur and 1+ pitting edema bilaterally. Laboratory studies show: Liver Function Test: Albumin: 3.9g/dl, Alkaline phosphatase: 230U/L, ALT(SGPT): 133U/L, AST(SGOT): 103U/L, Bilirubin unfractionated:1.1mg/dl, Total protein: 6.0g/dl. Hematologic: Hematocrit: 29%, Leukocytes: 8,200/mm3, Platelets: 8,900/mm3, PT: 12sec (normal: 11 to 15 sec), aPTT: 22sec(normal: 20-35sec), Urine dipstick: Specific gravity: 1.030, Hemoglobin: Trace, Glucoose: 1+, Protein: 2+, Leukocyte esterase: negative, Nitrite: negative.The patient is hospitalized and placed on bed rest. Her hypertension is controlled with hydralazine, and she is placed on a magnesium sulfate drip for seizure prophylaxis. Over the next 3 days, her liver enzyme levels continue to climb and her platelet count drops to 50,000/mm3. Which of the following is an additional medication that should be given at this time?

229) A 31-year-old woman comes to your office seeking advice about birth control. She had her third child 3 months ago and does not wish to get pregnant in the near future. Her medical history is significant for HIV infection with a CD4 count of 500 cells/mm3 and a viral load of 2000 copies/mL. She also has migraine headaches with an aura that she has had since the age of 14 years. She has never had surgery. She takes no medications and has no known drug allergies. She has a family history significant for breast, endometrial, and ovarian cancers. Her physical examination, including breast and pelvic examination, is normal. Which of the following conditions represents a contraindication to the combined oral contraceptive pill for this patient?

230) A healthy 32-year-old woman vaginally delivers a healthy full-term baby boy. You are called to consult postpartum because the patient has difficulty with voiding. The delivery was the patient’s third child and was uncomplicated. However, by the end of her second day of hospitalization she is able to urinate only 25 cc at a time. Straight catheterization by the nurse reveals postvoid residuals of more than 300 cc. The patient denies any history of urinary tract infection, kidney stones, or prior voiding difficulties. She has no neurologic complaints. She has no significant past medical history. Surgical history is significant for a laparoscopic cholecystectomy 5 years ago. Her only medications are prenatal vitamins. She does not smoke or drink. On physical examination, she is in no distress but appears fatigued. She is afebrile and vital signs are normal. Heart and lung examination is within normal limits. Abdomen is appropriate for her recent delivery, soft and nontender. It is difficult to elicit any suprapubic distention. Rectal examination shows good sphincter tone. There are no gross neurologic deficits of the extremities. All of her laboratory studies are normal as well, and urinalysis does not show any leukocyte esterase, nitrites, or white blood cells. You prescribe bethanechol to help with her current urologic condition. As the prescribing physician, about which of the following side effects must you inform this patient?

231) A 52-year-old woman comes to clinic complaining of a persistent urinary tract infection. She tells you that she has had a burning, almost scalding sensation when she urinates. These symptoms have lasted months. Additionally, she has suffered from intermittent urinary incontinence for the last year, which has tended to correlate with the symptoms. Her primary care physician has treated her with trials of oral trimethoprim-sulfamethoxazole and levofloxacin, but she has had no improvement in her symptoms. She denies any fevers, flank pain, discharge, or recent sexual activity, though she notes that she is having severe hot flashes. Physical examination reveals a thin, friable vaginal mucosa with multiple small punctate hemorrhages. Which of the following is the most appropriate treatment?

232) A 36-year-old woman comes to your office concerned that she might become pregnant after her partner’s condom broke during intercourse 2 days ago. She wasn’t sure what to do, but some friends of hers told her that her doctor could still give her the “morning-after” pill. Her past medical history is significant for occasional tension headaches that resolve with acetaminophen. She smokes 0.5 pack cigarettes a day. She has never had surgery, takes no medications, and is allergic to sulfa drugs. Her family history is significant for ovarian cancer. Physical examination is normal. Laboratory evaluation demonstrates a positive urine HCG test. Which of the following represents an absolute contraindication to emergency contraception in this patient?

233) A 37-year-old woman, gravida 3, para 2, comes to her physician for follow-up on her ectopic pregnancy. She was diagnosed with an ectopic pregnancy 7 days ago and given methotrexate. She now presents with abdominal pain that started this morning. Examination is significant for moderate left lower quadrant tenderness. Laboratory analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that the ectopic pregnancy is roughly the same size but there is an increased amount of fluid in the pelvis. Which of the following is the most appropriate next step in management?

234) A 26-year-old woman comes to the physician because of a lump in her vagina. The lump is nontender but is uncomfortable when she walks. She states that for the last 6 years this lump has appeared about once a year. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She has no other medical problems. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. The rest of the pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?

235) You have just diagnosed a 21-year-old infertile woman with polycystic ovarian syndrome. The remainder of the infertility evaluation, including the patient’s hysterosalpingogram and her husband’s semen analysis, were normal. Her periods are very unpredictable, usually coming every 3 to 6 months. She would like your advice on the best way to conceive now that you have made a diagnosis. Which of the following treatment options is the most appropriate first step in treating this patient?

236) One of your patients with polycystic ovarian syndrome presents to the emergency room complaining of prolonged, heavy vaginal bleeding. She is 26 years old and has never been pregnant. She was taking birth control pills to regulate her periods until 4 months ago. She stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding 8 days ago. She has been doubling up on superabsorbant sanitary napkins 5 to 6 times daily since the bleeding began. On arrival at the emergency room, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her standing blood pressure is 108/66 mm Hg with a pulse of 126 beats per minute. While you wait for lab work to come back, you order intravenous hydration. After 2 hours, the patient is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%. She continues to have heavy bleeding. Which of the following is the best next step in the management of this patient?

237) A 29-year-old G0 comes to your OB/GYN office complaining of PMS. On taking a more detailed history, you learn that the patient suffers from emotional lability and depression for about 10 days prior to her menses. She reports that once she begins to bleed she feels back to normal. The patient also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous health-care provider placed her on oral contraceptives to treat her PMS 6 months ago. She reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms. Which of the following is the best next step in the treatment of this patient’s problem?

238) A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning hormone replacement therapy (HRT), but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She denies any medical problems and is not taking any medication except calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb. In counseling the patient regarding the risks and benefits of hormone replacement therapy, you should tell her that HRT (estrogen and progesterone) has been associated with which of the following?

239) A 48-year-old woman consults with you regarding menopausal symptoms. Her periods have become less regular over the past 6 months. Her last period was 1 month ago. She started having hot flushes last year. They have been getting progressively more frequent. She has several hot flushes during the day, and she wakes up twice at night with them as well. She has done quite a lot of reading about perimenopause, menopause, and hormone replacement therapy. She is concerned about the risks of taking female hormones. She wants to know what she should expect in regard to her hot flushes if she does not take hormone replacement. You should tell her which of the following?

240) A 32-year-old woman, gravida 2, para 2, comes to the physician for follow-up of an abnormal Pap test. One month ago, her Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy demonstrated acetowhite epithelium at 2 o'clock. A biopsy taken of this area demonstrated HGSIL. Endocervical curettage (ECC) was negative. The patient has no other medical problems, has never had cervical dysplasia, and takes no medications. Which of the following is the most appropriate next step in management?

241) A 31-year-old woman comes to the physician for follow-up after an abnormal Pap test and cervical biopsy. The patient's Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). This was followed by colposcopy and biopsy of the cervix. The biopsy specimen also demonstrated HGSIL. The patient was counseled to undergo a loop electrosurgical excision procedure (LEEP). Which of the following represents the potential long-term complications from this procedure?

242) A 22-year-old primigravid woman comes to the labor and delivery ward at term with regular, painful contractions. Her prenatal course was unremarkable. She has a past medical history significant for mitral valve prolapse with regurgitation demonstrated on echocardiography. She takes no medications and has no allergies to medications. Examination shows that her cervix is 4 centimeters dilated and the fetus is in vertex presentation. The fetal heart rate is reassuring. Which of the following is the most appropriate management of this patient?

243) A 16-year-old nulligravid woman comes to the emergency department because of heavy vaginal bleeding. She states that she normally has heavy periods every month but missed a period last month and this period has been unusually heavy with the passage of large clots. She has no medical problems, has no history of bleeding difficulties, and takes no medications. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 96/minute and respirations are 12/minute. Pelvic examination shows a moderate amount of blood in the vagina, a closed cervix, and a normal uterus and adnexae. Hematocrit is 30%. Urine hCG is negative. Which of the following is the most appropriate management?

244) A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2 days ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized uterus. Urine hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate of 160. The patient states that she is not sure whether to keep the pregnancy. Which of the following is the most appropriate next step in management?

245) You are discussing surgical options with a patient with symptomatic pelvic relaxation. Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal hysterectomy and anterior and posterior (A&P) repair for patients in which of the following circumstances?

246) A 63-year-old woman is undergoing a total abdominal hysterectomy (TAH) for atypical endometrial hyperplasia. She mentioned to her doctor 2 weeks prior to the surgery that she has had problems with leakage of urine with straining and occasional episodes of urinary urgency. A urine culture at that visit is negative. She has had preoperative cystometrics done in the doctor’s office showing loss of urine during Valsalva maneuvers along with evidence of detrusor instability. The doctor has elected to do a retropubic bladder neck suspension following the TAH. A Marshall-Marchetti-Krantz procedure (MMK) is done to attach the bladder neck to the pubic symphysis. The patient does well after her surgery and is released from the hospital on postoperative day 3. Which of the following should her doctor advise her prior to her discharge?

247) A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery?

248) A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing. Two years ago she chose to have an elective repeat cesarean delivery rather than attempt a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except that she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve prolapse, but no other structural cardiac disease. Which of the following is the correct management of this patient?

249) A 38-year-old woman, gravida 4, para 4, comes to the physician 8 days after a cesarean delivery complaining of redness and pain at the leftmost aspect of her incision. Her cesarean delivery was performed secondary to a non reassuring fetal heart rate tracing. She was feeling well after the operation until 4 days ago, when she developed pain and redness around her incision. Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 88/min, and respirations are 12/min. There is marked erythema and induration around the incision. At the left margin of the incision there is a fluctuant mass. Which of the following is most appropriate next step in management?

250) A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a gush of fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions present, oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having contractions every minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal heart rate changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the cervix is 6 cm dilated. Which of the following is the most appropriate next step in management?

251) A 22-year-old primigravid woman at term comes to the labor and delivery ward because of painful contractions every 2 minutes. She has had no gush of fluid and no bleeding from the vagina. Her prenatal course was unremarkable. She takes no medications and has no allergies to medications. Examination shows that her cervix is 6 cm dilated and 100% effaced; the fetus is at 0 station. The fetal heart rate has a baseline in the 150s and is reactive. The patient desires an epidural for pain relief. Which of the following should be given orally shortly before the epidural is placed?

252) A 39-year-old woman, gravida 4, para 3, comes to the physician for a prenatal visit. Her last menstrual period was 8 weeks ago. She has had no abdominal pain or vaginal bleeding. She has no medical problems. Examination is unremarkable except for an 8-week sized, nontender uterus. Prenatal labs are sent. The rapid plasma reagin (RPR) test comes back as positive and a confirmatory microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP) test also comes back as positive. Which of the following is the most appropriate pharmacotherapy?

253) A 21-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician because of a malodorous vaginal discharge. She states that she first noticed the discharge 2 days ago and since then it has become more profuse and malodorous. Her prenatal course has been unremarkable during this pregnancy. Her prior pregnancy was complicated by preterm labor and delivery at 31 weeks' gestation. Examination shows a grayish vaginal discharge. A strong amine odor is released when KOH is applied to a sample of the discharge. Examination of a normal saline ("wet") preparation reveals numerous "clue" cells. Which of the following is the most appropriate pharmacotherapy?

254) A 23-year-old woman comes to the physician because she thinks that she may be pregnant. She missed her last two periods and feels "different." A urine pregnancy test is positive and an ultrasound reveals a 12-week fetus. The patient is very concerned because she received the measles-mumps-rubella (MMR) vaccine four months ago and was told to wait 3 months before attempting conception. The pregnancy is desired. The patient asks if she should have a termination of pregnancy because she was vaccinated shortly before becoming pregnant. Which of the following is the most appropriate response?

255) A 22-year-old woman comes to the physician because of a missed menstrual period. She has a complex past medical history. She has hypothyroidism, for which she takes thyroxine, she has an artificial heart valve, for which she takes Coumadin, and she recently started tetracycline for acne. She does not think that she is pregnant because she is currently on the oral contraceptive pill, but, if pregnant, she would keep the pregnancy. Physical examination, including pelvic examination, is unremarkable. Urine human chorionic gonadotropin (hCG) is positive. Which of the following medications should the patient continue to take during the pregnancy?

256) A 19-year-old nulligravid woman comes to the emergency department because of severe left lower quadrant pain. She has been noticing this pain intermittently for the past 3 days, but this afternoon it became persistent and severe and was accompanied by nausea and vomiting. Examination shows left lower quadrant tenderness and a tender left adnexal mass. Urine hCG is negative. Pelvic ultrasound shows a 7 cm left ovarian complex mass. Which of the following is the most appropriate next step in management?

257) A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and swelling in her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal thrombus in the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an advantage of low molecular-weight heparin compared with unfractionated heparin?

258) A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy with no significant past medical history. Examination is significant for a temperature of 38.3 C (101 F), moderate costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine. The patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two days, she rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty, feeling no pain, and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in management?

259) A 47-year-old woman comes to the physician for an annual examination. One year ago, she was diagnosed with endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She was found to have grade I, stage I, disease at that time. Over the past year, she has developed severe hot flashes that occur throughout the day and night and are worsening. She is also concerned because her mother and several of her aunts have severe osteoporosis. She wonders whether she can take estrogen replacement therapy. Which of the following is the most appropriate response?

260) A 32-year-old woman, gravida 3, para 0, at 29 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. She had a prophylactic cerclage placed at 12 weeks' gestation because of her history of two consecutive 20-week losses. These spontaneous abortions were both characterized by painless cervical dilation, with the membranes found bulging into the vagina on examination. Ultrasound now demonstrates her cervix to be long and closed with no evidence of funneling. Which of the following is the most appropriate time to remove the cerclage from this patient?

261) A 55-year-old woman comes to the physician because of hot flashes. She first noted them about 9 months ago, and since then they have been worsening. She states that the flashes come on at various times throughout the day, but that they are especially intense at night. She had her last menstrual period approximately 5 months ago. Her medical history is significant for a pulmonary embolus at the age of 36 and severe depression. She takes fluoxetine for depression and has no allergies to medications but smokes one pack of cigarettes per day. Physical examination is unremarkable, including a normal pelvic examination. Which of the following is the most appropriate pharmacotherapy for this patient?

262) A 42-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the physician for her first prenatal visit. She has no complaints. She has a history of Trichomonas infection, but no other medical problems. Examination is significant for a 10-week sized, nontender uterus. During the speculum examination, a Pap smear is performed and gonorrhea and Chlamydia screening tests are taken. The next day, the gonorrhea test returns as positive. Which of the following is the most appropriate pharmacotherapy?

263) A 54-year-old woman comes to the physician because of hot flashes. She states that her hot flashes have been steadily worsening over the past year since she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for menometrorrhagia. Pathology from the surgery showed low grade endometrial hyperplasia. She has no medical problems and takes no medications. Her family history is unremarkable except for a strong family history of osteoporosis. She states that the hot flashes have become absolutely debilitating for her and she wants to take something that will give her the best chance of stopping them. Which of the following is the most appropriate pharmacotherapy?

264) A 22-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. She has had some nausea but no other complaints. She has had no bleeding per vagina or abdominal pain. She had an ovarian cystectomy at age 18 but no other medical or surgical problems. She takes no medications and has no known drug allergies. Examination is unremarkable except for an 8-week-sized non-tender uterus. The patient wants information on vitamin supplementation during pregnancy. Which of the following represents the correct amount of vitamin A supplementation this patient should take daily?

265) A 29-year-old woman comes to the emergency department because of abdominal distension and shortness of breath. Approximately 1 week ago, she underwent fertility treatment with ovulation induction and oocyte retrieval. She has a history of polycystic ovarian syndrome but no other medical problems. She had laparoscopy 1 year ago as part of a fertility evaluation. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 80/40 mm Hg, pulse is 130/min, and respirations are 28/min. Physical examination is remarkable for crackles at the lung bases bilaterally and a distended, nontender abdomen with a fluid wave. Ultrasound demonstrates bilaterally enlarged ovaries (each >10 cm) and free fluid in the abdomen. Urine hCG is negative. Which of the following is the most likely diagnosis?

266) A 24-year-old woman, gravida 3, para 2, comes to the physician for her first prenatal visit. Her last menstrual period was 8 weeks ago, and a home pregnancy test was positive. She states that this pregnancy, like her last two pregnancies, was unintended. She had been using condoms for birth control in all three instances. She had normal vaginal deliveries 2 and 4 years ago. Which of the following is the most likely reason for condom failure?

267) A 38-year-old woman, gravida 1, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has had no bleeding from the vagina or abdominal pain and no complaints. She has a long history of migraine headache and recently developed peptic ulcer disease (PUD). Examination shows a nontender 8-week sized uterus but is otherwise unremarkable. The patient is very concerned that her migraine headaches and peptic ulcer disease will make her pregnancy intolerable. Which of the following is the most appropriate response?

268) A 31-year-old African-American woman is diagnosed with uterine fibroids. Which of the following types of fibroids is most likely to interfere with conception and pregnancy?

269) A 19-year-old nulligravid woman comes to the physician for a routine annual check-up. She complains of weight gain of approximately 10 lbs (4.5 kg) over the last year. She feels that this is related to her oral contraceptive pill use. She has no previous medical problems. She became sexually active at the age of 18. She has been sexually active with one partner for the past 2 months. She and her partner use condoms inconsistently, but use combination oral contraceptive pills regularly for contraception. Vital signs are normal. Her body mass index is 25 kg/m2. Physical examination shows no abnormalities. Which of the following is the most appropriate advice to give to this patient?

270) Mifepristone is an effective abortifacient if given within 72 hours of intercourse. Mifepristone contains which of the following?

271) A 45-year-old African-American woman who was diagnosed with PCOS in her early twenties presents to her gynecologist for her annual visit. One of her close friends has recently been diagnosed with ovarian cancer, so she is concerned about her own cancer risk. Menarche was at age 14 years, and she has yet to go through menopause. She has a healthy 19-yearold daughter. She has no family history of cancer. She does not smoke or drink and exercises regularly. Aside from a diagnosis of PCOS, she is otherwise in good health. Given her health history, which of the following statements is true?

272) A pregnant woman is discovered to be an asymptomatic carrier of Neisseria gonorrhoeae. A year ago, she was treated with penicillin for a gonococcal infection and developed a severe allergic reaction. Which of the following is the treatment of choice at this time?

273) A 17-year-old woman at 22 weeks gestation presents to the emergency center with a 3-day history of nausea, vomiting, and abdominal pain. The pain started in the middle of the abdomen and is now located along her mid to upper right side. She is noted to have a temperature of 38.4C (101.1F). She denies any past medical problems or surgeries. How does pregnancy alter the diagnosis and treatment of the disease?

274) An 18-year-old G1 has asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks gestation. Which of the following statements is true?

275) A 20-year-old female at 34 weeks of gestation develops a lower urinary tract infection. Which of the following is the best choice for treatment?

276) A 30-year-old African-American woman with type-1 diabetes and hypertension comes to the physician's office after obtaining a positive result from a home pregnancy test. She takes insulin and enalapril. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (99.0F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable. Her BUN is 18 mg/dl and creatinine is 1.4 mg/dl. A repeat 13-HCG test performed in the office confirms pregnancy. Which of the following is the most appropriate next step in management?

277) A 33-year-old woman at 10 weeks presents for her first prenatal examination. Routine labs are drawn and her hepatitis B surface antigen is positive. Liver function tests are normal and her hepatitis B core and surface antibody tests are negative. Which of the following is the best way to prevent neonatal infection?

278) A 25-year-old G2P0 at 30 weeks gestation presents with the complaint of a new rash and itching on her abdomen over the last few weeks. She denies any constitutional symptoms or any new lotions, soaps, or detergents. On examination she is afebrile with a small, papular rash on her trunk and forearms. Excoriations from scratching are also noted. Which of the following is the recommended first-line treatment for this patient?

279) A 23-year-old G3P2002 presents for a routine obstetric (OB) visit at 34 weeks. She reports a history of genital herpes for 5 years. She reports that she has had only two outbreaks during the pregnancy, but is very concerned about the possibility of transmitting this infection to her baby. Which of the following statements is accurate regarding how this patient should be counseled?

280) 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?

281) A 21-year-old G2P1 at 25 weeks gestation presents to the emergency room complaining of shortness of breath. She reports a history of asthma and states her peak expiratory flow rate (PEFR) with good control is usually around 400. During speaking the patient has to stop to catch her breath between words; her PEFR is 210. An arterial blood gas is drawn and oxygen therapy is initiated. She is afebrile and on physical examination expiratory wheezes are heard in all lung fields. Which of the following is the most appropriate next step in her management?

282) A 20-year-old G1 at 38 weeks gestation presents with regular painful contractions every 3 to 4 minutes lasting 60 seconds. On pelvic examination, she is 3 cm dilated and 90% effaced; an amniotomy is performed and clear fluid is noted. The patient receives epidural analgesia for pain management. The fetal heart rate tracing is reactive. One hour later on repeat examination, her cervix is 5 cm dilated and 100% effaced. Which of the following is the best next step in her management?

283) 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?

284) A 32-year-old G3P2 at 39 weeks gestation with an epidural has been pushing for 30 minutes with good descent. The presenting fetal head is left occiput anterior with less than 45 degree of rotation with a station of +3 of 5. The fetal heart rate has been in the 90s for the past 5 minutes and the delivery is expedited with forceps. Which of the following best describes the type of forceps delivery performed?

285) A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated; spontaneous rupture of membranes occurred prior to admission. She has had one prior uncomplicated vaginal delivery and denies any medical problems or past surgery. She reports an allergy to sulfa drugs. Currently, her vital signs are normal and the fetal heart rate tracing is reactive. Her prenatal record indicates that her Group B streptococcus (GBS) culture at 36 weeks was positive. What is the recommended antibiotic for prophylaxis during labor?

286) A 23-year-old G1 at 38 weeks gestation presents in active labor at 6 cm dilated with ruptured membranes. On cervical examination the fetal nose, eyes, and lips can be palpated. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. The patient’s pelvis is adequate. Which of the following is the most appropriate management for this patient?

287) You are following a 38-year-old G2P1 at 39 weeks in labor. She has had one prior vaginal delivery of a 3800-g infant. One week ago, the estimated fetal weight was 3200 g by ultrasound. Over the past 3 hours her cervical examination remains unchanged at 6 cm. Fetal heart rate tracing is reactive. An intrauterine pressure catheter (IUPC) reveals two contractions in 10 minutes with amplitude of 40 mm Hg each. Which of the following is the best management for this patient?

288) A primipara is in labor and an episiotomy is about to be cut. Compared with a midline episiotomy, which of the following is an advantage of mediolateral episiotomy?

289) 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?

290) A 19-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are very painful and occurring every 3 to 5 minutes. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 4 to 12 minutes. The nurse states that the contractions are mild to moderate to palpation. On examination the cervix is 1 cm dilated, 60% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Which of the following is the most appropriate next step in the management of this patient?

291) A 38-year-old G3P2 at 40 weeks gestation presents to labor and delivery with gross rupture of membranes occurring 1 hour prior to arrival. The patient is having contraction every 3 to 4 minutes on the external tocometer, and each contraction lasts 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and no decelerations. The patient has a history of rapid vaginal deliveries, and her largest baby was 3200 g. On cervical examination she is 5 cm dilated and completely effaced, with the vertex at −2 station. The estimated fetal weight is 3300 g. The patient is in a lot of pain and requesting medication. Which of the following is the most appropriate method of pain control for this patient?

292) 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?

293) A 25-year-old G3P2 at 39 weeks is admitted in labor at 5 cm dilated. The fetal heart rate tracing is reactive. Two hours later, she is reexamined and her cervix is unchanged at 5 cm dilated. An IUPC is placed and the patient is noted to have 280 Montevideo units (MUV) by the IUPC. After an additional 2 hours of labor, the patient is noted to still be 5 cm dilated. The fetal heart rate tracing remains reactive. Which of the following is the best next step in the management of this labor?

294) 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?

295) 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 38.3C (101F). 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?

296) A 28-year-old G1 at 38 weeks had a normal progression of her labor. She has an epidural and has been pushing for 2 hours. The fetal head is direct occiput anterior at +3 station. The fetal heart rate tracing is 150 beats per minute with variable decelerations. With the patient’s last push the fetal heart rate had a prolonged deceleration to the 80s for 3 minutes. You recommend forceps to assist the delivery owing to the nonreassuring fetal heart rate tracing. Compared to the use of the vacuum extractor, forceps are associated with an increased risk of which of the following neonatal complications?

297) You performed a forceps-assisted vaginal delivery on a 20-year-old G1 at 40 weeks for maternal exhaustion. The patient had pushed for 3 hours with an epidural for pain management. A second-degree episiotomy was cut to facilitate delivery. Eight hours after delivery, you are called to see the patient because she is unable to void and complains of severe pain. On examination you note a large fluctuant purple mass inside the vagina. What is the best management for this patient?

298) A 20-year-old G1 at 41 weeks has been pushing for 21/2 hours. The fetal head is at the introitus and beginning to crown. It is necessary to cut an episiotomy. The tear extends through the sphincter of the rectum, but the rectal mucosa is intact. How should you classify this type of episiotomy?

299) A 16-year-old G1P0 at 38 weeks gestation comes to the labor and delivery suite for the second time during the same weekend that you are on call. She initially presented to labor and delivery at 2:00 PM Saturday afternoon complaining of regular uterine contractions. Her cervix was 1 cm dilated, 50% effaced with the vertex at −1 station, and she was sent home after walking for 2 hours in the hospital without any cervical change. It is now Sunday night at 8:00 PM, and the patient returns to labor and delivery with increasing pain. She is exhausted because she did not sleep the night before because her contractions kept waking her up. The patient is placed on the external fetal monitor. Her contractions are occurring every 2 to 3 minutes. You reexamine the patient and determine that her cervix is unchanged. Which of the following is the best next step in the management of this patient?

300) A 24-year-old G1P1 presents for her routine postpartum visit 6 weeks after an uncomplicated vaginal delivery. She states that she is having problems sleeping and is feeling depressed over the past 2 to 3 weeks. She reveals that she cries on most days and feels anxious about taking care of her newborn son. She denies any weight loss or gain, but states she doesn’t feel like eating or doing any of her normal activities. She denies suicidal or homicidal ideation. Which of the following is true regarding this patient’s condition?

301) A 35-year-old G3P3 presents to your office 3 weeks after an uncomplicated vaginal delivery. She has been successfully breast-feeding. She complains of chills and a fever to 38.3C (101F) at home. She states that she feels like she has flu, but denies any sick contacts. She has no medical problems or prior surgeries. The patient denies any medicine allergies. On examination she has a low-grade temperature of 38C (100.4F) and generally appears in no distress. Head, ear, throat, lung, cardiac, abdominal, and pelvic examinations are within normal limits. A triangular area of erythema is located in the upper outer quadrant of the left breast. The area is tender to palpation. No masses are felt and no axillary lymphadenopathy is noted. Which of the following is the best option for treatment of this patient?

302) A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breast-feed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. Which of the following would prevent her from breast-feeding?

303) A 23-year-old G2P2 requires a cesarean delivery for arrest of active phase. During labor she develops chorioamnionitis and is started on ampicillin and gentamicin. The antibiotics are continued after the cesarean delivery. On postoperative day 3, the patient remains febrile and symptomatic with uterine fundal tenderness. No masses are appreciated by pelvic examination. She is successfully breast-feeding and her breast examination is normal. Which antibiotic should be initiated to provide better coverage?

304) 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?

305) A 28-year-old G2P2 presents to the hospital 2 weeks after vaginal delivery with the complaint of heavy vaginal bleeding that soaks a sanitary napkin every hour. Her pulse is 89 beats per minute, blood pressure 120/76 mm Hg, and temperature 37.1C (98.9F). Her abdomen is nontender and her fundus is located above the symphysis pubis. On pelvic examination, her vagina contained small blood clots and no active bleeding is noted from the cervix. Her uterus is about 12 to 14 weeks size and nontender. Her cervix is closed. An ultrasound reveals an 8-mm endometrial stripe. Her hemoglobin is 10.9, unchanged from the one at her vaginal delivery. β-hCG is negative. Which of the following potential treatments would be contraindicated?

306) You are called to see a 37-year-old G4P4 for a fever to 38.7C (101.8F). She is postoperative day 3 after cesarean delivery for arrest of active-phase labor. She underwent a long induction for postdate pregnancy and had rupture of membranes for more than 18 hours. Her other vital signs include pulse 118 beats per minute, respiratory rate 16 breaths per minute, and blood pressure 120/80 mm Hg. She complains of some incisional and abdominal pain, but is otherwise fine. HEENT, lung, breast, and cardiac examinations are within normal limits. On abdominal examination she has uterine fundal tenderness. Her incision has mild erythema around the staple edges and serous drainage along the left side. Pelvic examination reveals a tender uterus, but no adnexal masses. Which of the following is the most appropriate antibiotic to treat this patient with initially?

307) You are doing postpartum rounds on a 23-year-old G1P1 who is postpartum day 2 after an uncomplicated vaginal delivery. As you walk in the room, you note that she is crying. She states she can’t seem to help it. She denies feeling sad or anxious. She has not been sleeping well because of getting up every 2 to 3 hours to breast-feed her new baby. Her past medical history is unremarkable. Which of the following is the most appropriate treatment recommendation?

308) A 20-year-old G1P1 is postpartum day 2 after an uncomplicated vaginal delivery of a 6-lb 10-oz baby boy. She is trying to decide whether to have you perform a circumcision on her newborn. The boy is in the wellbaby nursery and is doing very well. In counseling this patient, you tell her which of the following recommendations from the American Pediatric Association?

309) 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?

310) 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?

311) You are making rounds on a 29-year-old G1P1 who underwent an uncomplicated vaginal delivery at term on the previous day. The patient is still very confused about whether she wants to breast-feed. She is a very busy lawyer and is planning on going back to work in 4 weeks, and she does not think that she has the time and dedication that breast-feeding requires. She asks you what you think is best for her to do. Which of the following is an accurate statement regarding breast-feeding?

312) A 22-year-old G1P1 who is postpartum day 2 and is bottle-feeding complains that her breasts are very engorged and tender. She wants you to give her something to make the engorgement go away. Which of the following is recommended to relieve her symptoms?

313) A 36-year-old G1P1 comes to see you for a routine postpartum examination 6 weeks after an uncomplicated vaginal delivery. She is currently nursing her baby without any major problems and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for birth control. She does not have any medical problems. She is a nonsmoker and is not taking any medications except for her prenatal vitamins. Which of the following methods may decrease her milk supply?

314) 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?

315) A 39-year-old G3P3 comes to see you on day 5 after a second repeat cesarean delivery. She is concerned because her incision has become very red and tender and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 38.8C (102F). Physical examination indicates that the Pfannenstiel incision is indeed erythematous and is open about 1 cm at the left corner, and is draining a small amount of purulent liquid. There is tenderness along the wound edges. Which of the following is the best next step in the management of this patient?

316) A 72-year-old G5P5 presents to your office for well-woman examination. Her last examination was 7 years ago, when she turned 65. She has routine checks and laboratory tests with her internist each year. Her last mammogram was 6 months ago and was normal. She takes a diuretic for hypertension. She is a retired school teacher. Her physical examination is normal. Which of the following is the best vaccination to recommend to this patient?

317) A 15-year-old woman presents to your office for her first wellwoman examination while she is on summer break from school. She denies any medical problems or prior surgeries. She had chicken pox at age 4. Her menses started at the age of 12 and are regular. She has recently become sexually active with her 16-year-old boyfriend. She states that they use condoms for contraception. Her physical examination is normal. Which of the following vaccines is appropriate to administer to this patient?

318) A 26-year-old woman presents to your office for her well-woman examination. She denies any medical problems or prior surgeries. She states that her cycles are monthly. She is sexually active and uses oral contraceptive pills for birth control. Her physical examination is normal. As part of preventive health maintenance, you recommend breast self-examination and instruct the patient how to do it. Which of the following is the best frequency and time to perform breast self-examinations?

319) A 29-year-old woman, gravida 2, para 1, at 37 weeks gestation was admitted to the hospital. Her previous pregnancy was uncomplicated and she delivered a 3,500 g (7.7lb) baby vaginally. The current pregnancy demonstrated a breech presentation at 30 weeks gestation. A repeat ultrasonogram now shows persistent frank breech presentation with an estimated fetal weight of 2,800 g (6lb). No fetal or uterine abnormalities are noted. She has intact membranes. Examination shows a closed cervix. Fetal heart monitoring is reassuring. Which of the following is the most appropriate next step in management?

320) A 19-year-old primigravid woman at 32 weeks gestation comes to the physician's office because of weight gain and mild generalized body swelling. She has no previous medical problems and her pregnancy has been otherwise uncomplicated. Her blood pressure is 150/90 mm Hg. Physical examination shows mild generalized edema; the remainder of her examination is unremarkable. A fetal heart tracing is reassuring. Laboratory studies show: Hematocrit: 48%, Platelets: 230,000/mm3, Serum creatinine: 1.0 g/dl, Alanine aminotransferase: 35 U/L, Urinalysis: 2+protein. Amniotic fluid analysis shows immature fetal lungs. She lives close to the hospital and is compliant with medication follow-ups. Which of the following is the most appropriate next step in management?

321) A 32-year-old woman, gravida 3, para 2, at 30 weeks gestation comes to the hospital because of new onset painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her second pregnancy was complicated by preterm labor at 28 weeks gestation. She has no discharge, leakage of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0C (98.7F), blood pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft, partially effaced and posterior cervix dilated to 2cm. A Nitrazine test is negative. Nonstress test shows a reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is the most appropriate next step in management?

322) 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?

323) A 48-year-old G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. She had a vaginal hysterectomy for fibroids and menorrhagia. She denies any medical problems, but has not seen a doctor in 6 years. Her family history is significant for stroke, diabetes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 3 in tall, and weighs 85 kg. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and temperature 37C (98.4F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal. The next appropriate step in the management of this patient’s blood pressure is which of the following?

324) 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?

325) A 25-year-old woman has a positive cervical culture for Neisseria gonorrhoeae. She has had at least two positive cultures for gonorrhea treated in the past. She is afebrile and has no symptoms. The incidence of penicillin-resistant gonorrhea in some areas of the United States is currently as great as 10%. Because of this, the recommended treatment for gonorrhea includes which of the following?

326) A 34-year-old woman presents to the physician's office for infertility evaluation. Her cycles have been irregular for the past 12 months and she hasn't had any periods for the past 3 months. Previously, her cycles were quite regular. She also has hot flashes, dyspareunia and mood disturbances. She has been married for 6 years and has a three-year-old daughter. She has a history of Hashimoto thyroiditis and is on thyroid replacement therapy. She smokes one pack of cigarettes daily. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, and serum prolactin is normal. Serum TSH is within normal limits. Which of the following is the most appropriate treatment for her infertility?

327) You are seeing a 38-year-old woman for her annual gynecologic examination. She asks you for some information regarding the HPV vaccine and whether you think it would be appropriate for her 17-year-old daughter. Which of the following statements regarding the quadrivalent human papillomavirus vaccine and HPV is true?

328) A 24-year-old woman lost her previous two pregnancies at approximately 20 weeks’ gestation, without having noted any contractions. She is currently at 15 weeks’ gestation and denies having uterine contractions. Her cervix is undilated and uneffaced. Which of the following is the most appropriate management of this patient?

329) On a routine annual examination, a 43-yearold woman is found to have a 2-cm mass in the lateral aspect of her right breast. Which of the following is the most appropriate next step in management?

330) A nurse called to report a low grade temperature in a 20-year-old woman who delivered a healthy baby 12 hours earlier. She had a normal vaginal delivery, and the placenta was delivered spontaneously. She had shaking chills during and ten minutes following the delivery. She continues to have bloody vaginal discharge. Her temperature is 38.0C (100.4F), blood pressure is 120/80 mmHg, pulse is 76/min and respirations are 14/min. Pelvic examination shows bloody discharge along with small blood clots on the introitus and vaginal walls. Her uterus is soft and non-tender. Laboratory studies show a WBC of 11 ,000/mm3 with 78% neutrophils. Which of the following is the most appropriate next step in management?

331) A healthy 32-year-old primigravid woman at 12 weeks' gestation comes for a routine prenatal visit. She has no complaints. She does not smoke or consume alcohol. She has blood group 0, Rh+ and her husband has blood group AB, Rh+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. You respond that although the child will have a blood group different from hers, alloimmunization is of little concern because?

332) A 37-year-old pregnant woman has a genetic amniocentesis at 16 weeks’ gestation. A concurrent ultrasound shows normal fetal anatomy. Her prenatal course has been unremarkable. Her prenatal laboratory tests include a B negative blood type, a negative rubella antibody titer, a negative hepatitis B surface antigen, and a hematocrit of 31%. Which of the following is the most appropriate management for this woman?

333) A 19-year-old primigravida at term has been completely dilated for 21/2 hours. The vertex is at 2 to 3 station, and the position is occiput posterior. She complains of exhaustion and is unable to push effectively to expel the fetus. She has an anthropoid pelvis. Which of the following is the most appropriate management to deliver the fetus?

334) A pregnant woman has been taking phenytoin (Dilantin) for a seizure disorder. She is concerned that the drug will cause fetal abnormalities. Which of the following defects is the most common anomaly associated with phenytoin?

335) A 39-year-old woman known to have fibrocystic disease of the breast complains of persistent fullness and pain in both breasts. Which of the following drugs will be most effective in relieving her symptoms?

336) A couple consults you because each has neurofibromatosis and wish to know what their reproductive possibilities are. You should tell them which of the following?

337) A 35-year-old woman at 30 weeks’ gestation discovers a lump in her left breast. Examination reveals a 2–3 cm, firm nodule in the upper outer quadrant. Which of the following is the most appropriate next step in the management of this patient?

338) A 1-cm carcinoma of the breast is diagnosed by an excisional biopsy in a 36-year-old woman at 14 weeks’ gestation. The axillary nodes are negative. Which of the following is the best management of this patient?

339) A 19-year-old woman, gravida 1, para 1, is immediately status post a normal spontaneous vaginal delivery and normal third stage when she develops brisk bright red bleeding from the vagina. Her prenatal course was unremarkable. She has asthma, which worsened during the pregnancy. Ten years ago, she had a tonsillectomy. She takes a steroid and albuterol inhaler. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 115/min, and respirations are 16/min. Her abdomen is soft and non-tender. Her uterus is soft and "boggy" to palpation. Pelvic examination reveals no evidence of a laceration. Which of the following treatments should be avoided in managing this patient's postpartum hemorrhage?

340) A 36-year-old woman, gravida 3, para 3, is 2 days status post cesarean section for dystocia when she begins wandering the hallways of the hospital at 2 AM. She is extremely confused and thinks that she is at the police station. She states that she cannot sleep, feels very anxious, and wants to hurt her baby. Her prenatal course was unremarkable. She has no medical problems and had never had surgery. She has been taking Tylenol with codeine postpartum for incisional pain. Which of the following is the most appropriate next step in the management?

341) A 23-year-old woman, gravida 2, para 1 at 26 weeks' gestation, comes to the physician because of fevers and pain in the middle of the back on the right side. Her fevers started 2 days ago, and the back pain began yesterday. Her temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 110/min, and respirations are 16/min. She has left costovertebral angle tenderness. Her abdomen is benign and gravid. Her laboratory values show leukocytes of 18,000/mm3. Urinalysis reveals white blood cells that are too numerous to count per high powered field. Which of the following is the most appropriate pharmacotherapy for this patient?

342) A 42-year-old woman, gravida 4, para 3, at 38 weeks' gestation, comes to the labor and delivery ward complaining of contractions. She has had type 1 diabetes since the age of 20. She has a history of syphilis that was adequately treated 4 years ago. She took insulin and prenatal vitamins throughout the pregnancy. Otherwise, her prenatal course was unremarkable, including normal screening. Her blood pressure is 140/90 mm Hg. Her cervix is 4 cm dilated and 100% effaced. She is admitted. Which of the following IV medications will this patient likely require during labor and delivery to prevent neonatal complications?

343) A 22-year-old female comes to the physician complaining of pain during sexual activity. She is unable to have intercourse because her vagina becomes tense, resulting in intense pain upon penetration. She is living with her boyfriend and this is her first sexual relationship. She now avoids intercourse because of her fear of the pain. She has no history of serious illness. Speculum examination is not possible due to tense perineal musculature. Which of the following is the most appropriate next step in management?

344) A 19-year-old college student presents to her primary care physician for emergency contraception. She had unprotected sexual intercourse 48-hours ago while on a trip to Mexico with her boyfriend. She wants to prevent pregnancy. Her last menstrual period was 18-days ago. She has no previous medical problems. Family history is significant for migraines in her mother. She does not use tobacco, alcohol or drugs. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

345) A 26-year-old woman, gravida 2, para 2, complains of loss of small amounts of urine immediately after a spontaneous vaginal delivery. She received epidural anesthesia during labor and delivery because of severe pain. She has no fever, dysuria, urgency, or hematuria. She has no other medical problems, takes no medication except prenatal vitamins, and has no known drug allergies. Her vital signs are normal. Examination shows a soft, non-tender abdomen. Pelvic examination is normal. The patient voids 30-40ml of urine each time; her postvoid residual volume is 400 ml. The patient's labs reveal: Urine: Specific gravity: 1.020, Blood: trace, Glucose: negative, Leukocyte esterase: negative, Nitrites: negative, WBC: 1-2/hpf, RBC: 3-4/hpf. Which of the following is the most appropriate treatment for her incontinence?

346) A 54-year-old woman undergoes a laparotomy because of a pelvic mass. At exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. Which of the following is the most appropriate intraoperative course of action?

347) A 58-year-old woman is seen for evaluation of a swelling in her right vulva. She has also noted pain in this area when walking and during coitus. At the time of pelvic examination, a mildly tender, fluctuant mass is noted just outside the introitus in the right vulva in the region of the Bartholin gland. Which of the following is the most appropriate treatment?

348) A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. The patient above now asks you for your advice on how to treat her cervical disease. Your best recommendation is for the patient to undergo which of the following?

349) A woman is found to have a unilateral invasive vulvar carcinoma that is 2 cm in diameter but not associated with evidence of lymph node spread. Initial management should consist of which of the following?

350) Stage Ib cervical cancer is diagnosed in a young woman who wishes to retain her ability to have sexual intercourse. Your consultant has therefore recommended a radical hysterectomy. Assuming that the cancer is confined to the cervix and that intraoperative biopsies are negative, which of the following structures would not be removed during the radical hysterectomy?

351) A 38-year-old woman, gravida 2, para 1, at 10 weeks gestation comes to the physician's office for prenatal counseling of genetic disorders. She has a healthy 3-year-old child. Given her age, she is worried about the risk of Down syndrome, and if her baby test is positive for Down syndrome she would like to terminate the pregnancy. Ultrasonogram shows increased fetal nuchal fold lucency. Which of the following is the most appropriate next step in management?

352) A 57-year-old woman comes to the physician's office for evaluation of vaginal dryness, burning and dyspareunia. She also has dysuria and increased urinary frequency. The symptoms have been present for several months but have intensified recently. She has tried over-the-counter lubricants with little relief. Her last menstrual period was seven years ago. She takes hydrochlorothiazide for hypertension and pravastatin for hypercholesterolemia. Physical examination shows scarce pubic hair and reduced elasticity and turgor of the vulvar skin. Pale, dry and smooth vaginal epithelium is noted. Urine dipstick is normal. Which of the following is the most appropriate next step in management?

353) A 24-year-old woman presents for her first prenatal visit at 12 weeks gestation. She was diagnosed with HIV two years ago, and her most recent CD4 count three months ago was 600cells/mm3. She does not use tobacco, alcohol, or illicit drugs. Physical examination is within normal limits. Which of the following is the single most important intervention for reducing maternal-fetal transmission of HIV infection?

354) A 23-year-old woman presents for evaluation of infertility. For the past 12 months she has been having sexual intercourse without contraception but has not been able to conceive. Her history is significant for irregular periods for the past 2 years. She reports exercising intensely six days per week and acknowledges having a lot of stress at work. She smokes one pack of cigarettes daily. On physical examination, her vital signs are within normal limits. Her BMI is 18 kg/m2. Urine pregnancy test is negative. Laboratory studies show: Serum FSH: low, Serum LH: low, Serum prolactin: normal, Serum TSH: normal. Which of the following therapies would be most helpful for this patient's infertility?

355) A 26-year-old G1P1 woman requests contraception after delivering a healthy baby three weeks ago. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

356) A 24-year-old primigravid woman at 35 weeks gestation comes to the emergency department with uterine contractions. She started these contractions six hours earlier, and they have not increased in intensity since then. The contractions started in the lower abdomen and are irregular. Her pregnancy has been uncomplicated. Her prenatal course, prenatal tests and fetal growth have been normal. She has no history of trauma. She does not use tobacco, alcohol or drugs. Vital signs are normal. Examination shows a firm, posterior and closed cervix. Ultrasonogram in the emergency department shows a gestational age of 35-weeks and the fetus in the vertex presentation. Fetal heart tones are heard. She feels better after mild sedation. Which of the following is the most appropriate next step in management?

357) A 23-year-old primigravid female at 38 weeks' gestation was admitted to the delivery room for management of labor. She was in active labor for 4-hours during which her cervical dilation progressed from 3cm to 8cm, and descent progressed from - 1 to +1 station. Examination 6-hours later showed the same degree of dilation and descent. The fetal head is in the Left Occipita Anterior (LOA) position. An external tocometer is placed and reveals contractions 3 min apart, lasting 50 seconds each. Internal pelvic assessment shows prominent ischial spines. FetaI heart monitoring shows a baseline of 140 bpm with frequent accelerations. Prenatal ultrasound at 37-weeks showed a fetus of average size. Which of the following is the most appropriate next step in management?

358) A 16-year-old female comes to the emergency department because of heavy vaginal bleeding. She has no pain. Since menarche, menses have been irregular. She has a steady boyfriend and uses condoms for contraception. She has no other medical problems. She does not use alcohol, tobacco, or drugs. Her temperature is 37C (99F), blood pressure is 110/60 mm Hg, pulse is 90/min, and respirations are 16/min. Physical examination shows active vaginal bleeding. Pregnancy test is negative. Coagulation studies are within normal limits. Ultrasound shows no abnormalities. Her hemoglobin is 9.8 g/dl and hematocrit is 29%. Which of the following is the most appropriate next step in management?

359) A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?

360) A 24-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to you for a routine prenatal visit. She has had mild constipation. She has had no nausea, vomiting, fever, burning urination, back pain, or other complaints. She has no history of urinary tract infections. She takes iron and folic acid supplements. She does not use tobacco, alcohol, or drugs. She is afebrile; her blood pressure is 124/74 mm Hg and pulse is 78/min. Examination shows a uterus consistent in size with a 16-week gestation. Physical examination shows no abnormalities. Urinalysis is within normal limits. A routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli. Which of the following is the most appropriate next step in management?

361) A 65-year-old woman is found to have osteoporosis on DEXA scan. She underwent right knee surgery five years ago and developed post-operative deep venous thrombosis, for which she was treated with 6 months of warfarin therapy. She also has severe gastroesophageal reflux disease and takes lansoprazole daily. Her mother died of breast cancer, her maternal aunt has endometrial cancer, and her paternal aunt has a history of ovarian cancer. She does not want to use bisphosphonates because of her reflux symptoms, and would like to consider raloxifene. Which of the following is a contraindication to raloxifene in this patient?

362) A 37-year-old obese, hypertensive female comes to the physician because of intermenstrual bleeding and heavy menses. Endometrial biopsy shows "complex hyperplasia without atypia." She has two young healthy children and does not want more children in the future. W hich of the following is the most appropriate next step in management?

363) A 27-year-old nulliparous woman presents to your office complaining of a 7-week history of amenorrhea with a negative urine pregnancy test. Upon further questioning, she says that she feels fine and does not have any symptoms. She has a steady boyfriend and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any medications beside vitamin supplements to help her in her workout. She is a senior college student and works as a secretary in a law firm. On physical examination, there is no hirsutism or galactorrhea. The rest of the examination reveals nothing abnormal. Her BMI is 28 kg/m2. Initial work-up reveals the following: Serum TSH 2.5 mU/mL (N= 0.5-5.0), Prolactin 10 ng/ml (< 20 ng/ml). According to these findings, which of the following is the most appropriate next step in the management of this patient?

364) A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid from her vagina that started 10 hours earlier. She has chronic hypertension and was prescribed methyldopa throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the vagina; the cervix is 80% effaced and 3cm dilated. Ultrasound shows a small for gestational age fetus in the vertex presentation with a decreased amniotic fluid index. Fetal heart monitoring shows repetitive late decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most appropriate next step in management?

365) A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?

366) A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of gushing bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. She is anxious and concerned about her baby. Which of the following is the most appropriate next step in management?

367) A 23-year-old woman who is 10 weeks pregnant with her first pregnancy is referred to you for smoking cessation. She has been smoking since the age of 21 and has never tried to quit. However, now that she is pregnant she would really like to quit. She has no symptoms of depression. Her past medical history is significant for asthma. She uses an inhaler occasionally for her asthma and takes no other medications. She has never had surgery and has no known drug allergies. Physical examination is normal for a patient at 10 weeks’ gestation. Which of the following is the most appropriate management for this patient?

368) A 42-year-old woman with hypertension and a past history of an ectopic pregnancy 18 years earlier comes to your office and reports one episode of unprotected sexual intercourse 6 days ago. Her last menstrual period was normal and occurred 2 weeks earlier. She is concerned about unintended pregnancy and asks you about the “Morning After” pill. She reports no other complaints, has been healthy recently, and her hypertension has been well controlled. She has smoked one pack of cigarettes per day for the past 20 years. Which of the following factors in this patient would be a relative contraindication to prescribing hormonal emergency contraception?

369) A 29-year-old woman, gravida 2, para 1, at 33 weeks’ gestation is referred to your office because of a possible herpes outbreak. She developed a painful vesicular rash a few days ago in her genital area. She has never before had any similar symptoms. She has no other medical problems, takes no medications, and has no known drug allergies. Examination reveals numerous erythematous vesicles and ulcerations. Testing of the lesion demonstrates herpes simplex virus infection and serologic testing reveals that it is a primary outbreak for the patient. Which of the following is the most appropriate management of this patient?

370) A 35-year-old woman with type 2 diabetes comes to your office seeking pregnancy advice. Although she is not currently pregnant and has never been pregnant, she and her spouse, are planning to have their first child. She has previously managed her diabetes with diet and exercise. Approximately 4 months ago, however, you started her on metformin, as her fasting blood glucose levels were consistently elevated. Her hemoglobin A1c level at that time was 9%. She has no specific complaints today and her physical examination is unremarkable. A hemoglobin A1c level drawn 1 week before today’s visit is 6.2%. She would like to know which, if any, diabetic medications she can take during her pregnancy. Which of the following is the most appropriate pharmacologic monotherapy for her?

371) A 42-year-old woman comes to your office for an annual examination. She states that she has been feeling good over the past year. She exercises three times a week and watches her diet. She has no medical problems. She had an appendectomy at the age of 25, and no other surgeries. She uses a 35μg combined oral contraceptive pill (OCP) daily, and takes no other medications. She has been on “the pill” for birth control for the past 10 years and is happy with it. She has no known drug allergies. Physical examination, including breast and pelvic exams, is normal. She wants to know if she can continue to take the oral contraceptive pill. Which of the following is the most appropriate advice to give her?

372) A 24-year-old woman comes to your office with vaginal spotting 2 weeks after a missed menstrual period. Her past medical history is significant for pelvic inflammatory disease. She has never had surgery. She takes no medications and is allergic to penicillin. Examination demonstrates scant blood in the vaginal vault and minimal right adnexal tenderness. Laboratory evaluation reveals a beta-hCG value of 1600 mIU/mL. Blood type is O positive. Hematocrit is 39%. Pelvic ultrasound demonstrates nothing in the uterus and a right adnexal mass consistent with ectopic pregnancy. The decision is made to proceed with intramuscular methotrexate for medical treatment of the ectopic pregnancy. Which of the following is the most likely side effect from this treatment?

373) A 4-year-old girl is brought to the physician by her mother because of a bloody, greenish, malodorous vaginal discharge. The discharge was first noted 3 days ago and has worsened since then. The girl has no other symptoms. The mother reports no concerns regarding abuse of the child. Examination is attempted but impossible because of the child's absolute refusal to be examined. Several efforts at persuasion are made but are unsuccessful. Which of the following is the most appropriate next step in management?

374) A 22-year-old G3P0030 obese female comes to your office for a routine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at age 15. She has had three first-trimester voluntary pregnancy terminations. She uses Depo-Provera for birth control, and reports occasionally using condoms as well. She has a history of genital warts, but denies any prior history of abnormal Pap smears. The patient denies use of any illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. However, 3 weeks later you receive the results of her Pap smear, which shows a high-grade squamous intraepithelial lesion (HGSIL). Which of the following factors in this patient’s history does not increase her risk for cervical dysplasia?

375) After making a diagnosis in the patient in question 319, you recommended that she wear loose clothing and cotton underwear and to stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?

376) A 29-year-old G0 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. In the patient described in the question above, which of the following is the best treatment?

377) A 32-year-old women presents to the emergency room complaining of severe lower abdominal pain. She says she was diagnosed with pelvic inflammatory disease by her gynecologist last month, but did not take the medicine that she was prescribed because it made her throw up. She has had fevers on and off for the past 2 weeks. In the emergency room, the patient has a temperature of 38.3C (101F). Her abdomen is diffusely tender, but more so in the lower quadrants. She has diminished bowel sounds. On bimanual pelvic examination, bilateral adnexal masses are palpated. The patient is sent to the ultrasound department, and a transvaginal pelvic ultrasound demonstrates bilateral tubo-ovarian abscesses. Which of the following is the most appropriate next step in the management of this patient?

378) A 36-year-old woman presents to the emergency room complaining of pelvic pain, fever, and vaginal discharge. She has had nausea and vomiting and cannot tolerate liquids at the time of her initial evaluation. The emergency room physician diagnoses her with pelvic inflammatory disease and asks you to admit her for treatment. Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?

379) A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An endometrial sampling done in the office shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound done at the hospital demonstrates multiple, large uterine fibroids. Which of the following is the best treatment option for this patient?

380) You see five postmenopausal patients in the clinic. Each patient has one of the conditions listed, and each patient wishes to begin hormone replacement therapy today. Which one of the following patients would you start on therapy at the time of this visit?

381) A mother brings her 14-year-old daughter in to the office for consultation. The mother says her daughter should have started her period by now. She is also concerned that she is shorter than her friends. On physical examination, the girl is 4-ft 10 in tall. She shows evidence of breast development at Tanner stage 2. She has no axillary or pubic hair. You reassure the mother that her daughter seems to be developing normally. Educating the mother and daughter, your best advice is to tell them which of the following?

382) An 18-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche and is accompanied by nausea and headache. History is otherwise unremarkable, and pelvic examination is normal. You diagnose primary dysmenorrhea and recommend initial treatment with which of the following?

383) A 7-year-old girl is brought in to see you by her mother because the girl has developed breasts and has a few pubic hairs starting to show up. Which of the following is the best treatment for the girl’s condition?

384) A 30-year-old female comes to the office complaining of vaginal discharge, dyspareunia and vulvar pruritus. She has a history of hypothyroidism and takes thyroid replacement therapy. She uses tobacco and alcohol every day. On examination, you notice a thin, grayish vaginal discharge and erythema and edema of the vulva and vaginal mucosa. The pH of the discharge is 6.0 and wet-mount examination reveals pear-shaped motile organisms. First line treatment is prescribed for both the patient and her partner. The patient must avoid which of the following during the treatment period?

385) A 19-year-old woman comes to the physician for a routine physical examination. She has no complaints. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no significant past medical history and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72 mm Hg. Complete physical examination, including pelvic examination, is unremarkable. A cervical swab is sent for nucleic acid amplification of Chlamydia trachomatis and Neisseria gonorrhoeae. The nucleic acid amplification test returns positive for chlamydia infection and negative for gonorrhea. The patient is still asymptomatic. Which of the following is the most appropriate next step in management?

386) A 28-year-old woman, gravida 3, para 2, at 35 weeks gestation is rushed to the emergency department because of vaginal bleeding. She was sleeping when she first noticed the bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 14th week of gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. Her previous pregnancies were uncomplicated. Her temperature is 37.0C (98.7F), blood pressure is 90/60 mmHg, pulse is 11 6/min and respirations are 16/min. Physical examination shows cold extremities and bright red vaginal bleeding. Which of the following is the most appropriate next step in management?

387) A 25-year-old G2 P1 woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

388) A 20-year-old woman presents with complaints of vaginal discharge and vulvar pruritus. She has no other medical problems. Physical examination reveals a thin, malodorous vaginal discharge and erythema of the vulva and vaginal mucosa. No other exam abnormalities are noted. Wet-mount preparation of the discharge shows motile pear-shaped organisms. Which of the following management options is most appropriate?

389) A 28-year-old woman comes to the physician's office at 30 weeks gestation because she has not felt her baby's movements for the past week. Fetal heart tones are not heard by Doppler. An ultrasound shows an absence of fetal cardiac activity. Fetal demise is diagnosed. She underwent a cesarean section for her previous delivery to avoid a post-term pregnancy. She has no other medical problems. Vital signs are normal and physical examination shows no abnormalities. Her cervix is 3 cm dilated and 70 percent effaced. Laboratory studies show a platelet count of 230,000/mm and a fibrinogen level of 480 mg/dl (normal: 150-450mg/dl). Both the patient and her husband are shocked after hearing the news of fetal demise. Which of the following is the most appropriate next step in management?

390) An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?

391) A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease last year, for which she was hospitalized. She has currently been sexually active with the same partner for the past year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits. Which of the following statements is true regarding spermicides found in vaginal foams, creams, and suppositories?

392) A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?

393) A 19-year-old woman presents for voluntary termination of pregnancy 6 weeks after her expected (missed) menses. She previously had regular menses every 28 days. Pregnancy is confirmed by β-human chorionic gonadotropin (β-hCG), and ultrasound confirms expected gestational age. Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?

394) A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant. Her last menstrual period was one week ago. She describes no other symptoms. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the nipples, and it is guaiac negative. Which of the following is the most appropriate next step in management?

395) A 27-year-old female comes to the physician's office for evaluation of infertility. She has not been able to conceive for 12 months despite frequent intercourse. Her menses started at age 12 and have always been irregular. She uses over the counter acne medications. She is also obese and has been unsuccessful with weight loss. Physical examination shows an obese woman with sparse hair over the upper lip. There is no galactorrhea, thyromegaly or clitoromegaly. Which of the following is the most appropriate therapy for this patient's infertility?

396) A 20-year-old, gravida 1, para 0, at 10 weeks gestation is brought to the emergency department because of moderate vaginal bleeding. She has a colicky suprapubic pain radiating to the back and denies the passage of tissue through her introitus. She does not use tobacco, alcohol or drugs. She has no history of trauma or serious illness. Her temperature is 37.0C (98.7 F), blood pressure is 100/65 mm of Hg, pulse is 90/min and respirations are 17/min. Physical examination shows a dilated cervix and the products of conception can be seen through it. Her blood type is AB Rh negative and her antibody titer is 1:2. Ultrasonogram shows a ruptured gestational sac with no fetal heart motion. Which of the following is the most appropriate next step in management?

397) A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. Nonstress test is performed, and the strip is reactive and reassuring. Which of the following is the most appropriate next step in management?

398) A 24-year-old primigravid woman comes to the physician because of recent onset amenorrhea. Her last menstrual period was 7 weeks ago, and she has had nausea for the past 2 weeks. A urine pregnancy test is positive. She is being evaluated for dysphagia, and one-week ago she had a barium swallow examination. She is concerned for the baby because of her recent exposure to radiation. Which of the following is the most appropriate next step in management?

399) A 50-year-old woman presents to your office complaining of severe insomnia, hot flashes, and mood swings. She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart rate is 75/min. Serum TSH level is normal. You consider estrogen replacement therapy for this patient. Which of the following is most likely concerning estrogen replacement therapy in this patient?

400) A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?

401) A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?

402) A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered "unacceptable," so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?

403) A 21-year-old woman, gravida 2, para 1, at 28 weeks' gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy?

404) A 32-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?

405) A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?

406) A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother??

407) A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?

408) A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?

409) A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?

410) A 41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery?

411) A 22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?

412) A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?

413) A 34-year-old primigravid woman at 30 weeks' gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?