QRU genicology part 2 tiya

718. A 22-year-old woman delivers a 7-lb male infant at 40 weeks without any complications. On day 3 of life, the infant develops respiratory distress, hypotension, tachycardia, listlessness, and oliguria. What is the most likely cause of the infant’s illness?

719. 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?

720. 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?

721. 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 45o 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?

722. 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?

723. A 38-year-old G6P4 is brought to the hospital by ambulance for vaginal bleeding at 34 weeks. She undergoes an emergency cesarean delivery for fetal bradycardia under general anesthesia. In the recovery room 4 hours after her surgery, the patient develops respiratory distress and tachycardia. Lung examination reveals rhonchi and rales in the right lower lobe. Oxygen therapy is initiated and chest x-ray is ordered. Which of the following is most likely to have contributed to her condition

724. 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?

725. A 32-year-old G3P2 at 39 weeks gestation presented to the hospital with ruptured membranes and 4 cm dilated. She has a history of two prior vaginal deliveries, with her largest child weighing 3800 g at birth. Over the next 2 hours she progresses to 7 cm dilated. Two hours later, she remains 7 cm dilated. The estimated fetal weight by ultrasound is 3200 g. Which of the following labor abnormalities best describes this patient?

726. 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?

727. 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?

728. 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?

729. A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. 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 2 to 10 minutes. The nurse states that the contractions are mild to palpation. On examination the cervix is 2 cm dilated, 50% 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 stages of labor is this patient in?

730. 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?

731. 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?

732. 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?

733. 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?

734. A 29-year-old G2P1 at 40 weeks is in active labor. Her cervix is 5 cm dilated, completely effaced, and the vertex is at 0 station. She is on oxytocin to augment her labor and she has just received an epidural for pain management. The nurse calls you to the room because the fetal heart rate has been in the 70s for the past 3 minutes. The contraction pattern is noted to be every 3 minutes, each lasting 60 seconds, with return to normal tone in between contractions. The patient’s vital signs are blood pressure 90/40 mm Hg, pulse 105 beats per minute, respiratory rate 18 breaths per minute, and temperature 36.1C (97.6F). On repeat cervical examination, the vertex is well applied to the cervix and the patient remains 5 cm dilated and at 0 station, and no vaginal bleeding is noted. Which of the following is the most likely cause for the deceleration?

735. 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?

736. You are delivering a 33-year-old G3P2 and encounter a shoulder dystocia. After performing the appropriate maneuvers, the baby finally delivers, and the pediatricians attending the delivery note that the right arm is hanging limply to the baby’s side with the forearm extended and internally rotated. Which of the following is the baby’s most likely diagnosis?

737. 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?

738. 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?

739. 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?

740. 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?

741. 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?

742. A 25-year-old G1P0 patient at 41 weeks presents to labor and delivery complaining of gross rupture of membranes and painful uterine contractions every 2 to 3 minutes. On digital examination, her cervix is 3 cm dilated and completely effaced with fetal feet palpable through the cervix. The estimated weight of the fetus is about 6 lb, and the fetal heart rate tracing is reactive. Which of the following is the best method to achieve delivery?

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

744. A 34-year-old G3P2 delivers a baby by spontaneous vaginal delivery. She had scant prenatal care and no ultrasound, so she is anxious to know the sex of the baby. At first glance you notice female genitalia, but on closer examination the genitalia are ambiguous. Which of the following is the best next step in the evaluation of this infant?

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

746. A 27-year-old G4P3 at 37 weeks presents to the hospital with heavy vaginal bleeding and painful uterine contractions. Quick bedside ultrasound reveals a fundal placenta. The patient’s vital signs are blood pressure 140/92 mm Hg, pulse 118 beats per minute, respiratory rate 20 breaths per minute, and temperature 37C (98.6F). The fetal heart rate tracing reveals tachycardia with decreased variability and a few late decelerations. An emergency cesarean section delivers a male infant with Apgar scores of 4 and 9. With delivery of the placenta, a large retroplacental clot is noted. The patient becomes hypotensive, and bleeding is noted from the wound edges and her IV catheter sites. She requires 12 units of packed red blood cells and fresh frozen plasma for resuscitation. After a short stay in the intensive care unit the patient recovers. When can long-term complications related to sequela of postpartum hemorrhage first be noted?

747. On postoperative day 3 after an uncomplicated repeat cesarean delivery, the patient develops a fever of 38.2C (100.8F). She has no complaints except for some fullness in her breasts. On examination she appears in no distress; lung and cardiac examinations are normal. Her breast examination reveals full, firm breasts bilaterally slightly tender with no erythema or masses. She is not breast-feeding. The abdomen is soft with firm, nontender fundus at the umbilicus. The lochia appears normal and is nonodorous. Urinalysis and white blood cell count are normal. Which of the following is a characteristic of the cause of her puerperal fever?

748. A 38-year-old G3P3 begins to breast-feed her 5-day-old infant. The baby latches on appropriately and begins to suckle. In the mother, which of the following is a response to suckling?

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

750. A 26-year-old G1P1 is now postoperative day (POD) 6 after a low transverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 390C (102.2F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with firm, nontender uterus below the umbilicus. On pelvic examination her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative. Which of the following statements is true regarding this patient’s condition?

751. 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?

752. 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?

753. A 22-year-old G1 at 34 weeks is tested for tuberculosis because her father, with whom she lives, was recently diagnosed with tuberculosis. Her skin test is positive and her chest x-ray reveals a granuloma in the upper left lobe. Which of the following is true concerning infants born to mothers with active tuberculosis?

754. A 21-year-old G1 at 40 weeks, who underwent induction of labor for severe preeclampsia, delivered a 3900-g male infant via vaginal delivery after pushing for 21/2 hours. A second-degree midline laceration and sidewall laceration were repaired in the usual fashion under local analgesia. The estimated blood loss was 450 cc. Magnesium sulfate is continued postpartum for the seizure prophylaxis. Six hours after the delivery, the patient has difficulty voiding. Which is the most likely cause of her problem?

755. 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?

756. A 32-year-old G2P2 develops fever and uterine tenderness 2 days after cesarean delivery for nonreassuring fetal heart tones. She is placed on intravenous penicillin and gentamicin for her infection. After 48 hours of antibiotics she remains febrile, and on examination she continues to have uterine tenderness. Which of the following bacteria is resistant to these antibiotics and is most likely to be responsible for this woman’s infection?

757. 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?

758. 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?

759. 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?

760. A 22-year-old G1P0 has just undergone a spontaneous vaginal delivery. As the placenta is being delivered, a red fleshy mass is noted to be protruding out from behind the placenta. Which of the following is the best next step in management of this patient?

761. Following a vaginal delivery, a woman develops a fever, lower abdominal pain, and uterine tenderness. She is alert, and her blood pressure and urine output are good. Large gram-positive rods suggestive of clostridia are seen in a smear of the cervix. Which of the following is most closely tied to a decision to proceed with hysterectomy?

762. Three days ago you delivered a 40-year-old G1P1 by cesarean section following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse pages you to come to see the patient on the postpartum floor because she has a fever of 38.8C (102F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breast-feed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted. Her pelvic examination reveals uterine tenderness but no masses. Which of the following is the most likely diagnosis?

763. 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?

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

765. 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?

766. 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?

767. You are counseling a new mother and father on the risks and benefits of circumcision for their 1-day-old son. The parents ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?

A patient was induced for being postterm at 421/2 weeks. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical examination: a small amount of cartilage in the earlobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae. Based on this physical examination, what is the approximate gestational age of this male infant?

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

770. A 32-year-old G2P1 at 41 weeks is undergoing an induction of oligohydramnios. During the course of her labor, the fetal heart rate tracing demonstrates severe variable decelerations that do not respond to oxygen, fluid, or amnioinfusion. The patient’s cervix is dilated to 4 cm. A low-transverse cesarean delivery is performed for nonreassuring fetal heart tones. After delivery of the fetus you send a cord gas, which comes back with the following arterial blood values: pH 7.29, Pco2 50, and Po2 20. What condition does the cord blood gas indicate?

771. 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?

772. 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?

773. 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?

774. 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?

775. 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?

776. A 25-year-old G1P1 comes to see you 6 weeks after an uncomplicated vaginal delivery for a routine postpartum examination. She denies any problems and has been breast-feeding her newborn without any difficulties since leaving the hospital. During the bimanual examination, you note that her uterus is irregular, firm, nontender, and about a 15-week size. Which of the following is the most likely etiology for this enlarged uterus?

777. 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?

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

A 75-year-old G2P2 presents to your gynecology office for a routine examination. She tells you that she does not have an internist and does not remember the last time she had a physical examination. She says she is very healthy and denies taking any medication, including hormone replacement therapy. She has no history of abnormal Pap smears. She is a nonsmoker and has an occasional cocktail with her dinner. She does not have any complaints. In addition, she denies any family history of cancer. The patient tells you that she is a widow and lives alone in an apartment in town. Her grown children have families of their own and live far away. She states that she is self-sufficient and spends her time visiting friends and volunteering at a local museum. Her blood pressure is 140/70 mm Hg. Her height is 5 ft 4 in and she weighs 130 lb. Her physical examination is completely normal. Which of the following are the most appropriate screening tests to order for this patient?

780. 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?

781. A 65-year-old G3P3 presents to your office for annual checkup. She had her last well-woman examination 20 years before when she had a hysterectomy for fibroids. She denies any medical problems, except some occasional stiffness in her joints early in the morning. She takes a multivitamin daily. Her family history is significant for cardiac disease in both her parents and breast cancer in a maternal aunt at the age of 42 years. Her physical examination is normal. Which of the following is the most appropriate set of laboratory tests to order for this patient?

782. You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was normal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?

783. A 74-year-old woman presents to your office for well-woman examination. Her last Pap smear and mammogram were 3 years ago. She has hypertension, high cholesterol, and osteoarthritis. She stopped smoking 15 years ago, and denies alcohol use. Based on this patient’s history which of the following medical conditions should be this patient’s biggest concern?

784. A 16-year-old G0 female presents to your office for a routine annual gynecologic examination. She reports that she has previously been sexually active, but currently is not dating anyone. She has had three sexual partners in the past and says she diligently used condoms. She is a senior in high school and is doing well academically and has many friends. She lives at home with her parents and a younger sibling. She denies any family history of medical problems, but says her 80-year-old grandmother was recently diagnosed with breast cancer. She denies any other family history of cancer. She says she is healthy and has no history of medical problems or surgeries. She reports having had chicken pox. She smokes tobacco and drinks beer occasionally, but denies any illicit drug use. She had her first Pap smear and gynecologic examination last year with another doctor and reports that everything was normal. Her menses started at age 13 and are regular and light. She denies any dysmenorrhea. Her blood pressure is 90/60 mm Hg. Her height is 5 ft 6 in and she weighs 130 lb. Based on this patient’s history, what would be the most likely cause of death if she were to die at age 16?

785. A 17-year-old G1P1 presents to your office for her yearly wellwoman examination. She had an uncomplicated vaginal delivery last year. She has been sexually active for the past 4 years and has had six different sexual partners. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal discharge. She denies tobacco, alcohol, or illicit drug use. Which of the following are appropriate screening tests for this patient?

786. 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?

787. 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?

788. A 15-year-old woman presents to your office for her first well-woman examination. She has a history of asthma, for which she uses an inhaler as needed. She denies any prior surgeries. Her menses started at the age of 13 and are regular. She has recently become sexually active with her 17-year-old boyfriend. She states that they use condoms for contraception, but she is interested in something more effective. Which of the following is the most appropriate instrument to use when performing the Pap smear test in this patient?

789. A married 41-year-old G5P3114 presents to your office for a routine examination. She reports being healthy except for a history of migraine headaches. All her Pap smears have been normal. She developed gestational diabetes in her last pregnancy. She drinks alcohol socially, and admits to smoking occasionally. Her grandmother was diagnosed with ovarian cancer when she was in her fifties. Her blood pressure is 140/90 mm Hg; height is 5ft 5 in; weight is 150 lb. Which of the following is the most common cause of death in women of this patient’s age?

790. A 44-year-old G6P3215 presents for her well-woman examination. She tells you that all of her deliveries were vaginal and that her largest child weighed 2900 g at birth. How many full-term pregnancies did this patient have?

791. 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?

792. 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?

793. 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?

794. A 34-year-old woman comes to the physician for evaluation of vulvar lesions. Examination reveals multiple small teardrop shaped growths at the vestibule of the vulva. Application of trichloroacetic acid results incomplete resolution of the lesions. Which of the following is the most likely cause of her lesions?

795. A 40-year-old G3P2012 presents for her well-woman examination. She has had two vaginal deliveries and her largest baby weighed 4000 g. She had a postpartum bilateral tubal ligation. Her menstrual cycles are regular every 28 days and last 5 days. She states that with cough she may occasionally lose some urine; otherwise she has no complaints. She denies any medical problems. On examination she weighs 56 kg and her blood pressure is 132/81 mm Hg. What type of speculum would be most appropriate to use when performing this patient’s Pap test?

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

797. A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix. Since that time, all of her Pap tests have been normal. What recommendation should you make regarding how frequently she should undergo Pap smear testing?

798. A 45-year-old G3P3 presents for her yearly examination. She last saw a doctor 7 years ago after she had her last child. She had three vaginal deliveries, the last of which was complicated by gestational diabetes and preeclampsia. She has not been sexually active in the past year. She once had an abnormal Pap smear for which she underwent cryotherapy. She denies any medical problems. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67. Which of the following is best screening approach for this patient?

799. A 30-year-woman presents to your office with the fear of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer. You discuss with her the risks factors and prevention for ovarian cancer. Which of the following can decrease a woman’s risk of ovarian cancer?

800. 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?

801. 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?

802. 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?

803. Which of the following statements is true regarding contraception?

804. A 24-year-old nullipara is being evaluated for infertility. On pelvic examination, she has a single cervix. A diagnostic laparoscopy shows a double uterine fundus. Which of the following is the most likely diagnosis of her uterine anomaly?

805. A 58-year-old G6P4Ab2 diabetic woman who weighs 122.6 kg (270 lb) has her first episode of vaginal bleeding in 5 years. Her physician performs an outpatient operative hysteroscopy and dilatation and curettage (D&C). Which of the following is an indication for the procedure and the most likely diagnosis?

806. A pregnant woman is being followed by a nephrologist for chronic glomerulonephritis. Which of the following findings is normal at 28 weeks’ gestation?

807. 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?

808. A 37-year-old pregnant woman with type 2 diabetes mellitus and chronic hypertension is 35 weeks’ pregnant. Which of the following is the best test to screen for fetal well-being?

809. A 31-year-old primigravida develops gestational diabetes mellitus and is managed appropriately during pregnancy. She asks you about the consequences of gestational diabetes to her and her fetus. Which one of the following statements is correct?

810. A 7-year-old girl is brought to your office by her parents after they noticed the development of axillary and pubic hair 3 months ago. The girl has also experienced a significant growth spurt over the past year. There has been no change in her behavior or school performance. The girl denies headaches, vomiting or visual disturbances. Her personal and family medical histories are unremarkable. On examination, you note the presence of axillary hair, pubic hair at Tanner stage 2, and breast development at Tanner stage 3. Abdominal, genital and neurologic examinations reveal nothing abnormal. Her bone age is more than two standard deviations above normal. Serum FSH and LH levels are elevated. MRI of the brain is normal. Which of the following is the most likely cause of her symptoms?

811. A 53-year-old obese, postmenopausal woman presents to your office for a routine annual examination. Her last menstrual period was one year ago. Upon further questioning, she says that she sometimes experiences hot flashes of mild intensity. She is sexually active and denies vaginal dryness or dyspareunia. She has mild hypertension managed with hydrochlorothiazide and a salt-reduced diet. Her obstetrical history is significant for an elective termination of pregnancy at 35 years of age because of an abnormal MSAFP. Physical examination is normal. What is the most likely cause of the mild nature of the symptoms the patient is having?

812. A 28-year-old G2, P 1woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020 Blood: ++ Glucose: negative Ketones: negative Protein: negative Leukocyte esterase: negative Nitrites: negative What is the best next step in the management of this patient?

813. A 26-year-old woman comes to the physician’s office for evaluation of a vulvar ulcer that she noticed two days ago. Initially she had a small painless papule that later became ulcerated. Upon further questioning she reluctantly admits to using sex to obtain drugs. She also reports using oral contraceptives to prevent pregnancy. On vulvar examination there is a 2cm ulcer with a non-exudative base and a raised, indurated margin. Painless bilateral inguinal lymphadenopathy is present. Which of the following is the most likely diagnosis?

814. A 15-year-old girl is being evaluated for primary amenorrhea. Her previous medical history is unremarkable and she denies taking any medications. Examination reveals absent breasts as well as pubic and axillary hair. Vaginal examination could not be performed. Olfactory exam reveals an inability to identify different odors. Ultrasound shows a uterus and two ovaries; serum FSH level is 2 U/L (Normal is 4-30). Which of the following is the most likely karyotype to be found in this patient?

815. 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?

816. A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and metformin. She has no family history of gynecological malignancies. She does not use tobacco or alcohol. Her temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. Her BMI is 30 Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 10.8 g/dl and platelet count is 223,000/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?

817. A 23-year-old G1P0010 woman complains of severe dysmenorrhea (i.e., pain with menses). She misses work for the first 3 days of her menstrual cycle almost every month and states that this has been a problem for about 3 years, now getting worse. She is not currently sexually active and is not using any hormonal contraception. She complains of occasional deep abdominal pain after bowel movements. Subsequent laparoscopic evaluation reveals endometriosis. Which of the following is a true statement regarding this condition?

818. 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?

819. A 19-year-old primigravid woman at 39 weeks’ gestation is in active labor, and her cervix is 4 cm dilated, 90% effaced. Her amniotic membranes have been ruptured for 4 hours. Contractions are strong at 2- to 3-minute intervals and of 60- to 70-second duration. For the past 30 minutes, repetitive variable decelerations of the fetal heart rate have occurred. They have lasted 60–90 seconds, and the fetal heart rate has dropped as low as 60 beats per minute (BPM). You explain that there is a risk that the baby will become hypoxic and recommend a cesarean section. She refuses. Which of the following is the most appropriate course of action?

20. 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?

A 24-year-old woman has a MSAFP of 0.5 MOM (multiples of the median) at 17 weeks’ gestation. Which of the following fetal abnormalities is most likely to occur with this MSAFP?

822. A 69-year-old woman with diabetes mellitus complains of urinary incontinence. Her diabetes is well controlled with oral hypoglycemic agents. She has no complaints other than the wetness. Which of the following tests is most likely to demonstrate the cause?

823. A 48-year-old G5P5 woman has genuine stress incontinence (GSI). Kegel exercises have not helped, and her incontinence is gradually worsening. Her urethrovesical junction (UVJ) is prolapsed into the vagina, and her urethral closure pressure is normal. Which of the following procedures will most likely cure her incontinence?

824. 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?

825. A 45-year-old woman presents to her physician's office complaining of night sweats and insomnia. She states that for the past month she has woken up completely soaked with perspiration on several occasions. She has had irregular menstrual periods for the past six months. She consumes one ounce of alcohol nightly before going to the bed, and quit smoking 5 years ago. She has a history of hypertension controlled with hydrochlorothiazide. She denies illicit drug use. Her temperature is 36.7 C (98 F), blood pressure is 140/90 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Which of the following is the best next step in management?

826. A 14-year-old girl is being evaluated for short stature. She has not yet had any menstrual periods. She is not sexually active. She is at 6th percentile for height and 20th percentile for weight. Blood pressure is elevated in the upper extremities and low in the lower extremities. Lungs are clear to auscultation. If measured, which of the following is most likely to be present in this patient?

827. A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?

828. A 51-year-old woman comes to your office for a routine health maintenance examination. She says that she has been having irregular menses and occasional hot flashes for the past eight months. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but drinks two to three ounces of alcohol daily. She eats a pure vegetarian diet and walks two miles on a treadmill each day. Her vital signs are within normal limits. Her BMI is 31 kg/m2 Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?

829. A 16-year-old female presents to the ER complaining of left lower quadrant abdominal pain that started suddenly 24 hours ago. The pain does not radiate and is 5/ 10 in severity. She denies having fevers, vomiting, dysuria, diarrhea or vaginal bleeding. Her last menstrual period was two weeks ago. She takes no medications. On physical examination, her temperature is 37.20C (98.9.F), blood pressure is 11 0/65 mmHg, pulse is 80/min and respirations are 14/min. There is mild left lower quadrant tenderness without rebound or rigidity, and the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

830. 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 11 0/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?

831. A 30-year-old woman comes to the physician because of a 10-month history of dysmenorrhea associated with a dull pelvic sensation. She has heavy periods but denies inter-menstrual bleeding. She is sexually active with her husband and does not use contraception because they have been trying to become pregnant for one year. She has no pain during intercourse. Physical examination shows normal external genitalia and an enlarged uterus, but is otherwise normal. Which of the following is the most likely diagnosis?

832. A 16-year-old girl comes to the emergency department because of abdominal pain and vaginal bleeding. She has been sexually active with her boyfriend for the past year; they occasionally use condoms. This is their only means of contraception. Her last menstrual period was eight weeks ago. Previous menses occurred at regular 28-day intervals. She has had two episodes of pelvic inflammatory disease in the past year. Which of the following is the most appropriate next step in management?

833. A Caucasian couple presents to your office for infertility evaluation. They are unable to conceive after 14 months of unprotected sex. The woman is 23 years of age. Her menstrual periods are regular, occurring every 26 days. She denies perimenstrual pain or pelvic discomfort. Her last menstrual period was six days ago. Her past medical history is insignificant, and bimanual examination is normal. The man is 27 years old. He is not taking any medications. Physical examination, including external genitals, is normal. What is the best next step in the management of this couple?

834. 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 (1004F), 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?

835. 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:

836. 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?

837. 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?

838. 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?

839. 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?

840. 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?

841. A 26-year-old woman complains of a vaginal discharge causing burning and itching of the perineum. The pH of the discharge is 4.5. Which of the following is the most likely cause of her discharge?

842. A 45-year-old woman has bilateral breast pain that is most severe premenstrually. On palpation, there is excessive nodularity, tenderness, and cystic areas that diminish in size after menses. Which of the following is the most likely diagnosis?

843. Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?

844. 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?

845. 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?

846. 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?

847. 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?

848. A 19-year-old nulligravid woman at 38 weeks' gestation comes to her physician because she has passed bloody mucus discharge. Her prenatal course was unremarkable including a normal 19-week ultrasound. On speculum examination, there are no vaginal or cervical lesions. On vaginal examination, the cervix is 2 cm dilated and 100% effaced, and the fetus is at +1 station. The fetal heart rate has a baseline of 140 and is reactive. She has painful contractions every 2 minutes. One hour later the patient's cervix is 3 cm dilated, and a small amount of bloody mucus is noted on the examining glove. Which of the following is the most likely diagnosis?

849. 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?

850. 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?

851. 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?

852. 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?

853. A 28-year-old woman at 30 weeks gestation comes to the physician because of 2 days of a near absence of fetal movements. This is only her second prenatal visit because she has skipped many appointments. She has a medical history significant for chronic hepatitis C infection and a MRSA skin abscess that was drained. She smokes cigarettes and uses heroin, cocaine and alcohol. She says that she is trying hard to be sober. Her temperature is 37.0C (98.7F), blood pressure is 138/85 mm Hg and pulse is 80/min. Physical examination shows a fundal height of 26cm (10.2in). Fetal heart tones are heard by Doppler. Nonstress test (NST) shows no accelerations. After vibroacoustic stimulation, NST is still not reactive so a biophysical profile is ordered and shows a score of 2. Her lab work showed the following: Complete blood count Hemoglobin: 8.0 g/L MCV: 105fl Platelets: 120,000/mm3 Leukocyte count: 3,500/mm3 Which of the following is the most appropriate next step in management?

854. A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. She is known to be 0 (-) while her husband is 0 (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-0 immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-0 antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?

855. A 34-year-old woman, gravida 4, para 3, at 32 weeks gestation is brought to the emergency department because of vaginal bleeding. She has had no uterine contractions or abdominal pain. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 90/70 mm of Hg, pulse is 98/min and respirations are 18/min. Physical examination shows continuous bright red vaginal bleeding. Ultrasonogram in the emergency department shows complete placenta previa. Fetal heart tracing shows repetitive late decelerations. The patient's vital signs are stabilized, but the bleeding continues. Which of the following is the most appropriate next step in management?

856. A 24-year-old woman, G1P 1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

57. 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 mi. 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?

858. A 75-year-old woman comes to the physician complaining of vulvar itch that has been worsening for the past 2 years. She has had no bleeding from the vagina since she underwent menopause at the age of 52. She smokes five cigarettes per day. On physical examination she has a raised, pigmented lesion on the right labia majora. The rest of her physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

859. A 33-year-old, white woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of painful uterine contractions and heavy vaginal bleeding that started after she used intranasal cocaine. The patient's prenatal course was significant because she conceived while on the oral contraceptive pill, she occasionally used cocaine and heroin during the pregnancy, and she was found to be positive for group B Streptococcus colonization at 35 weeks. Fetal monitoring is not reassuring. The patient undergoes cesarean section, at which the uterus has a bluish hue. On inspection, the placenta is noted to have an adherent, retroplacental clot on 50% of its surface. Which of the following is the most likely initiating factor for this patient's presentation?

860. A 22-year-old primigravid woman at 32 weeks' gestation comes to the emergency department because of heavy vaginal bleeding and abdominal pain. Her prenatal course was unremarkable, including a normal 20- week ultrasound. Physical examination demonstrates a contracted uterus with hypertonus. A large "gush" of blood occurs during the cervical examination, which demonstrates a long and closed cervix. The fetal heart rate tracing shows severe late decelerations. Which of the following is the most appropriate next step in management?

861. A premenopausal, 48-year-old woman undergoes a routine mammographic screening. Physical examination is normal. Mammography identifies a suspicious focus with clustered micro-calcifications located deeply in the lateral upper quadrant of the right breast. No abnormality can be detected in this area on breast examination. Which of the following is the most appropriate next step in diagnosis?

862. A 64-year-old woman comes to the physician because she is "leaking" urine. She states that, over the past 3 years, she has had incontinence several times daily. She describes these episodes as small squirts of urine that come out whenever she laughs, coughs, sneezes, or engages in physical activity. Physical examination shows mild uterine prolapse and a moderate cystocele. Urine culture is negative. Postvoid residual is 25 ml (normal <50 mL) Cystometrogram is normal. Which of the following is the most likely diagnosis?

863. A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

864. A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm adnexal cyst is palpated. Ultrasound confirms a complex left adnexal mass with solid components that appear to contain bone and teeth. What percentage of these tumors are bilateral?

865. 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?

866. 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?

867. A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes. This patient is classified at which of the following stages?

868. 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. How should you classify or stage this patient’s disease?

869. 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?

870. 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?

871. A patient is receiving external beam radiation for treatment of metastatic endometrial cancer. The treatment field includes the entire pelvis. Which of the following tissues within this radiation field is the most radiosensitive?

872. An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?

873. A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

874. 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?

875. A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?

876. A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majora that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage characteristically would be first to which of the following nodes?

877. A 17-year-old girl is seen by her primary care physician for the evaluation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the ultrasound. Which of the following is the most common ovarian tumor in this type of patient?

878. A 41-year-old woman undergoes exploratory laparotomy for a persistent adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in this malignancy?

879. A postmenopausal woman presents with pruritic white lesions on the vulva. Punch biopsy of a representative area is obtained. Which of the following histologic findings is consistent with the diagnosis of lichen sclerosus?

880. A 21-year-old woman returns to your office for evaluation of an abnormal Pap smear. The Pap smear showed a squamous abnormality suggestive of a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy confirms the presence of a cervical lesion consistent with severe cervical dysplasia (CIN III). Which of the following human papilloma virus (HPV) types is most often associated with this type of lesion?

881. A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is done. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?

882. A patient is diagnosed with carcinoma of the breast. Which of the following is the most important prognostic factor in the treatment of this disease?

883. A 25-year-old woman presents to you for routine well-woman examination. She has had two normal vaginal deliveries and is healthy. She smokes one pack of cigarettes per day. She has no gynecologic complaints. Her last menstrual period was 3 weeks ago. During the pelvic examination, you notice that her left ovary is enlarged to 5 cm in diameter. Which of the following is the best recommendation to this patient?

884.A 23-year-old woman presents to your office complaining of growths around her vaginal opening. Recently, the growths have been itching and bleeding. On physical examination she has several broad-based lesions measuring 2 to 4 cm in diameter along the posterior fourchette. Although there is no active bleeding, the largest lesion appears to have been bleeding recently. Which of the following is the best way to treat this patient?

885. At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive. Without treatment, the next stage of this disease is clinically characterized by which of the following?

886. A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?

887. One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. A negative antibody titer is obtained. To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?

888. 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?

889. 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?

890. A 7-year-old girl is brought to your office by her parents after they noticed the development of axillary and pubic hair 3 months ago. The girl has also experienced a significant growth spurt over the past year. There has been no change in her behavior or school performance. The girl denies headaches, vomiting or visual disturbances. Her personal and family medical histories are unremarkable. On examination, you note the presence of axillary hair, pubic hair at Tanner stage 2, and breast development at Tanner stage 3. Abdominal, genital and neurologic examinations reveal nothing abnormal. Her bone age is more than two standard deviations above normal. Serum FSH and LH levels are elevated. MRI of the brain is normal. Which of the following is the most likely cause of her symptoms?

891. 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?

892. A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant for systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2. Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of her acne?

893. A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit, for the first time. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?

894. A 15-year-old girl is brought to the physician by her mother because she has not begun menstruating. She is otherwise healthy and has no medical problems. Vitals signs are within normal limits. Physical examination shows absence of breast development and no pubic hair is seen. Examination shows no other abnormalities. Ultrasound confirms the presence of a uterus. Which of the following is the most appropriate next step in management?

895. A 24-year-old woman, G1 P1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

896. A 22-year-old, gravida 1, para 0, at 13 weeks gestation is brought to the emergency department because of vaginal discharge and lower abdominal discomfort. She has had no passage of tissue from her vagina. She does not use tobacco, alcohol or drugs. She has no history of trauma. Her temperature is 37.0°C (98.7°F), blood pressure is 128/80 mmHg, pulse is 76/min and respirations are 14/min. Physical examination shows a closed cervix, a slightly tender uterus with a size consistent with gestational age, free adnexa and scant bright red bleeding from the introitus. Ultrasonogram in the emergency department shows normal fetal heart motion. She is anxious and concerned about her baby. Which of the following is the most likely diagnosis?

897. A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. Fetal heart monitoring is placed and shows a baseline rate of 130 beats/min, without any associated abnormalities. Pelvic examination shows the cervix is 50% effaced and 3cm dilated. Amniotomy is performed and a bloody show is noted. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70beats/min. As labor progresses, repetitive late decelerations are noted, as well as an increase in vaginal bleeding. Repeat vital signs of the patient shows a blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the most likely cause of the current condition?

898. A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. She does not use tobacco, alcohol or drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard. Which of the following is the next most appropriate step in management?

899. A 20-year-old woman, gravida 1, para 0, at 36 weeks gestation comes to the physician because of diffuse headache, blurry vision and epigastric pain. She has no previous history of hypertension, renal disease or neurologic disease. Her mother has a history of migraine headaches. Her temperature is 37.2 C (98.9 F), blood pressure is 200/126 mmHg and pulse is 80/min. Physical examination shows bilateral lower extremity edema. Deep tendon reflexes are exaggerated. Laboratory studies show: Blood urea nitrogen (BUN) 23 mg/dl Serum creatinine 1.6 mg/dl Blood glucose 98 mg/dl Urinalysis: Protein: 4+ Blood: negative Glucose: negative WBC: 1-2/hpf RBC: 1-2/hpf Casts: none Fetal heart tones are heard by Doppler. While evaluating her, she suddenly develops generalized tonic-clonic convulsions. Which of the following is the most accurate diagnosis of this new event?

900. A 29-year-old woman, gravida 3, para 2, at 35 weeks gestation is brought to the emergency department because of vaginal bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Four years ago, she had a low transverse cesarean section in her second pregnancy. Physical examination shows bright red vaginal bleeding. Her temperature is 37.0 C (98.7 F), blood pressure is 100/70 mm Hg, pulse is 90/min and respirations are 16/min. Fetal heart monitoring is reassuring. Which of the following is the most likely diagnosis?

901. 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 (98.7F), blood pressure is 11 0/60 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?

902. A 23-year-old woman, gravida 2, para 1, at 38 weeks' gestation was admitted to the delivery room for management of labor. On admission 6-hours ago, the patient was in the active phase of labor and the cervix was 4cm dilated. She was then placed under external tocometer and epidural anesthesia. Contractions were regular, occurring 2-3 minutes apart and lasting 40-60 seconds. She progressed well to 7cm. However, she has remained at 7cm the past 4-hours. The fetus is in the Left Occipita Anterior (LOA) position and at +1 station. Internal pelvic assessment shows prominent ischial spines. Electronic fetal heart monitoring shows 140 bpm with normal beat-to-beat and long term variability. Prenatal ultrasound at 37-weeks showed no abnormalities. Which of the following is the most likely cause of this patient's anomaly of labor?

903. A 24-year-old woman, gravida 2, para 1, at 36 weeks' gestation is brought to the emergency department after passing out. She is drowsy and moaning, complaining of abdominal pain. Her husband accompanies her. He states that she has not experienced any trauma, but that she experienced the sudden onset of severe abdominal pain before she passed out. She has no significant past medical history. Her pregnancy has been uncomplicated thus far. She does not use tobacco, alcohol, or drugs. She takes supplemental vitamins, but no other medications. Her temperature is 36.9 C (98.4F), blood pressure is 90/60 mm of Hg, and pulse is 130/min. Physical examination shows a cold and diaphoretic female. Examination shows a uterus consistent in size with a 36-week gestation; the cervical os is closed and no vaginal bleeding is noted. Which of the following is the most likely diagnosis?

904. 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?