Gyneco(51-100)

A 22-year-old G1 at 14 weeks gestation presents to your office with a history of recent exposure to her 3-year-old nephew who had a rubella viral infection. In which time period does maternal infection with rubella virus carry the greatest risk for congenital rubella syndrome in the fetus?

A 30-year-old class D diabetic is concerned about pregnancy. She can be assured that which of the following risks is the same for her as for the general population?

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

A 20-year-old G1 at 38 weeks gestation presents with regular painful contractions every 3 to 4 minutes lasting 60 seconds. On pelvic examina- tion, she is 3 cm dilated and 90% effaced; an amniotomy is performed and clear fluid is noted. The patient receives epidural analgesia for pain man- agement. 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?

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

A 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?

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 (oxytocin) decelerations. The patient’s pelvis is adequate. Which of the following is the most appropriate management for this patient?

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?

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 esti- mated 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?

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?

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

A 24-year-old primigravid woman, at term, has been in labor for 16 hours and has been dilated to 9 cm for 3 hours. The fetal vertex is in the right occiput posterior position, at +1 station, and molded. There have been mild late decelerations for the past 30 minutes. Twenty minutes ago, the fetal scalp pH was 7.27; it is now 7.20. For above clinical description, select the most appropriate procedure.

You have just delivered an infant weighing 2.5 kg (5.5 lb) at 39 weeks gestation. Because the uterus still feels large, you do a vaginal examination. A second set of membranes is bulging through a fully dilated cervix, and you feel a small part presenting in the sac. A fetal heart is auscultated at 60 beats per minute. For above clinical description, select the most appropriate procedure.

A 24-year-old woman (G3P2) is at 40 weeks gestation. The fetus is in the transverse lie presentation. For above clinical description, select the most appropriate procedure.

A nulliparous woman is in active labor (cervical dilation 5 cm with complete effacement, vertex at 0 station); the labor curve shows pro- tracted progression without descent following the administration of an epidural block. An IUPC shows contractions every 4 to 5 minutes, peaking at 40 mm Hg. Select the most appropriate treatment for above clinical situation.

A nulliparous woman has had arrest of descent for the past 2 hours and arrest of dilation for the past 3 hours. The cervix is dilated to 7 cm and the vertex is at +1 station. Monitoring shows a normal pattern and adequate contractions. Fetal weight is estimated at 7.5 lb. Select the most appropriate treatment for above clinical situation.

Appears to lengthen the second stage of labor. Match above description with the most appropriate type of obstetric anesthesia.

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 con- tractions 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 isn140 beats per minute with accelerations and no decelerations. Which of the following stages of labor is this patient in?

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?

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?

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?

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?

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?

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

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?

A 24-year-old G1P1 presents for her routine postpartum visit 6 weeks after an uncomplicated vaginal delivery. She states that she is having prob- lems 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?

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 side- wall laceration were repaired in the usual fashion under local analgesia. The estimated blood loss was 450 cc. Magnesium sulfate is continued post- partum for the seizure prophylaxis. Six hours after the delivery, the patient has difficulty voiding. Which is the most likely cause of her problem?

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?

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 con- tains about 10 cc of old, dark blood. The cervix is closed. Which of the fol- lowing is the most appropriate treatment?

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 37.1°C (98.9°F). Her abdomen is non- tender 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 non- tender. 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?

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?

Following a vaginal delivery, a woman develops a fever, lower abdom- inal 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?

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 signif- icant 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 38.8°C (102°F) 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 ten- der 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?

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?

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 well- baby nursery and is doing very well. In counseling this patient, you tell her which of the following recommendations from the American Pediatric Association?

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?

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?

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?

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?

A 36-year-old G1P1 comes to see you for a routine postpartum exam- ination 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?

A 30-year-old G3P3, who is 8 weeks postpartum and regularly breast-feeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness. Which of the following should you recommend to help her with this problem?

A 25-year-old G1P1 comes to see you 6 weeks after an uncompli- cated vaginal delivery for a routine postpartum examination. She denies any problems and has been breast-feeding her newborn without any diffi- culties 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?

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 inci- sion this morning. She has been experiencing general malaise and reports a fever of 38.8°C (102°F). Physical examination indicates that the Pfan- nenstiel 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 tender- ness along the wound edges. Which of the following is the best next step in the management of this patient?

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 dia- betes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8°C (100.1°F), pulse 69 beats per minute, respi- ratory 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?

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 nor- mal 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?

A 74-year-old woman presents to your office for well-woman exam- ination. 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?

A 17-year-old G1P1 presents to your office for her yearly well- woman 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 dis- charge. She denies tobacco, alcohol, or illicit drug use. Which of the fol- lowing are appropriate screening tests for this patient?

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 contracep- tive 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 fre- quency and time to perform breast self-examinations?

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 5 ft 5 in; weight is 150 lb. Which of the following is the most common cause of death in women of this patient’s age?

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 place- ment 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?