DES 2016. Final (Part 40)N

62) A 43-year-old primigravid woman at 10 weeks' gestation comes to the physician for a prenatal visit. She is feeling well except for some occasional nausea. She has had no bleeding from the vagina, abdominal pain, dysuria, frequency, or urgency. She has asthma for which she occasionally uses an inhaler. Examination is normal for a woman at 10 weeks gestation. Urine dipstick is positive for nitrites and leukocyte esterase and a urine culture shows 50,000 colony forming units per milliliter of Escherichia coli. Which of the following is the most appropriate next step in management?

63) A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response?

64) A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management?

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

66) A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding. She has colicky pain in the suprapubic region radiating to her back. Her temperature is 37.0C (98.7F), blood pressure is 110/76 mm Hg, pulse is 84/min, and respirations are 14/min. Physical examination shows a dilated cervix and the products of conception are seen through it. Blood is sent to the laboratory for type and antibody screen. The patient is treated with dilation and curettage and all products of conception are evacuated. She is stabilized and transferred to the ward. Her laboratory results are as follows: Hematocrit: 32%; Leukocyte count: 8,000 cells/μL; Blood type: AB; Rh-negative; Anti-Rh antibody titer: 1:4. Which of the following is the most appropriate next step in management?

67) A 29-year-old woman presents for a routine prenatal visit She is 24 weeks pregnant by last menstrual period and ultrasound. She does not have any medical problems and does not take any medications. She does not use tobacco, alcohol or illicit drugs. She works as a financial advisor in a local firm. She and her husband have been monogamous since getting married 5 years ago. Vital signs are normal. Physical examination shows no abnormalities. At the end of the visit she tells you that her newborn niece recently had a group B streptococcal infection and she is afraid that her child might develop the same. Which of the following is the most appropriate response?

68) The labor nurse calls you in your office regarding your patient who is 30 weeks pregnant and complaining of decreased fetal movement. The fetus is known to have a ventricular septal defect of the heart. The nurse has performed a nonstress test on the fetus. No contractions are seen. She thinks the tracing shows either a sinusoidal or saltatory fetal heart rate (FHR) pattern. Without actually reviewing the FHR tracing what can you tell the nurse?

69) You are counseling a 24-year-old woman who is a G2P1 at 36 weeks gestation. She delivered her first baby at 41 weeks gestation by cesarean section as a result of fetal distress that occurred during an induction of labor for mild preeclampsia. She would like to know if she can have a trial of labor with this pregnancy. Which of the following is the best response to this patient?

70) A 24-year-old woman with chronic hypothyroidism presents to her gynecologist for her annual examination. She recently got married, and she and her husband would like to conceive. Her hypothyroidism is well controlled and stable on thyroxine, and she has no other medical conditions. She is healthy and does not smoke or drink alcohol. She would like to know if she should keep taking her thyroxine. Which of the following is the best advice to give this patient?

71) A 32-year-old G3P3 woman is postoperative day 5 after an emergent cesarean section due to fetal distress. The patient progressed rapidly through passive labor without incident, but after her membranes were ruptured manually, a fetal scalp probe was placed in the active phase secondary to several runs of mid-late decelerations. Cesarean section was ultimately performed after 2 hours of active labor secondary to fetal distress. The patient presents now with a fever to 38.7C (101.7F) and uterine tenderness. Laboratory tests reveal a WBC count of 14,000/mm3, with 70% neutrophils and 4% bands. Which of the following is the most appropriate treatment?

72) A 32-year-old G3P3 woman presents to her obstetrician for help conceiving. She states her menstrual cycles have not been regular since the birth of her third child 3 years ago. Furthermore, although she readily became pregnant with her other three children, she has failed to become pregnant despite trying over the past 2 years. She has no significant past medical history and takes only prenatal vitamins. Although she says she has not been ill lately, she reports feeling “tired and cold all the time.” She also reports she has had trouble sleeping over the past several months. Her physical examination is normal. Laboratory tests show: WBC count: 9000/mm3; Hemoglobin: 8.0 g/dL; Platelet count: 300,000/mm3; Hematocrit: 40%; Thyroid-stimulating hormone level: 0.5 μU/mL; Free thyroxine: 2.0 ng/dL; Luteinizing hormone: 0.5 mU/mL; Follicle-stimulating hormone: 0.5 mU/mL. Which of the following will this woman likely need to take to conceive?

73) A 64-year-old woman undergoes left radical mastectomy for breast cancer. A 4-cm infiltrating ductal carcinoma is found on pathologic examination. Four of 20 axillary lymph nodes are positive for malignancy. Neoplastic cells are immunoreactive for estrogen and progesterone receptors. No evidence of metastatic disease is found on bone scanning with 99mTc-labeled phosphate or chest x-ray films. The patient receives appropriate radiation therapy and multidrug chemotherapy. Which of the following is the most appropriate adjunctive therapy in this setting?

74) A 23-year-old gravida 3, para 2 is admitted to the hospital at 31 weeks' gestation with painful uterine contractions. Her cervix is initially 3 cm dilated. Magnesium sulfate is started. Over the next 5 hours she progresses to full dilation. After a 1-hour second stage, she delivers a 2013-g (4-lb, 7-oz) newborn. In the neonatal intensive care unit, the infant develops respiratory distress and pneumonia. Over the following days the infant develops septicemia. Preliminary blood cultures demonstrate gram-positive cocci in chains. Treatment with which of the following would most likely have prevented this neonatal outcome?

75) 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 37.0 C (98.7 F), 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 2 cm. A Nitrazine test is negative. Non-stress 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?

76) A 17-year-old female comes to the physician's office for a routine physical examination. She has no complaints and has no previous medical problems. She has been having sex since the age of 14 and has had 3 sexual partners so far. Vital signs are stable and physical examination is unremarkable. Pap smear is performed and the report came back as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepithelial lesion). Which of the following is the most appropriate next step in management?

77) A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit. 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?

78) A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize. Which of the following is the most appropriate next step in management?

79) A 30-year-old G2 P 1woman at 38 weeks gestation presents to the hospital complaining of regular and painful uterine contractions that started two hours earlier. Pelvic examination reveals bulging membranes, and her cervix is 50% effaced and dilated to 3 cm. Her pregnancy was complicated by first trimester hemorrhage of unknown cause. Her past medical history is unremarkable. After placing a fetal heart monitor and an external tocometer on the patient, you note 3 separate 15 beat/min decreases in the fetal heart rate not coinciding with uterine contractions, each lasting for 25 seconds. Which of the following is the most appropriate next step in the management of this patient?

80) A 26-year-old G1 P1 woman requests contraception after delivering a healthy baby three weeks ago. She is breastfeeding the child and plans to continue for at least six months. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

81) 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?

82) A 24-year-old, gravida 0, para 0 woman comes to the physician because of an 8-week history of amenorrhea. She is sexually active and uses oral contraceptive pills for contraception. Her only other complaints are moderate fatigue and a decline in mood. She denies headaches, visual disturbances, and gastrointestinal symptoms. She has no other medical problems. She socially drinks alcohol and does not use tobacco or illicit drugs. She denies stress at home or work. She walks 1-2 miles every day. Her BMI is 24 kg/m2. Visual field test is within normal limits. Examination shows no hirsutism. Breast examination reveals a white, milky secretion upon expression of both nipples. Pelvic examination reveals a uterus of normal size. Initial investigations reveal a negative serum β-human chorionic gonadotropin (hCG) level. According to these findings, which of the following is the most appropriate next step in management?

83) A 30-year-old woman, gravida 2, para 1, at 37 weeks gestation is brought to the emergency department because of acute onset intense uterine contractions and vaginal bleeding. She has been followed closely for pre-eclampsia since her 32nd week of gestation. Her temperature is 37.0 C (98.7F), blood pressure is 140/86mmHg, pulse is 92/min and respirations are 18/min. Physical examination shows uterine tenderness and hyperactivity and moderate vaginal bleeding. Pelvic examination shows an effaced and 3cm dilated cervix. Ultrasonography shows a fundic placenta and a fetus in the cephalic position. Fetal heart tracing shows 140/min with good long-term and beat-to-beat variability. After initial resuscitation the bleeding is stopped Which of the following is the most appropriate next step in management?

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

85) An 81-year-old woman presents to your office complaining that her uterus fell out 2 months ago. She has multiple medical problems, including chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes significant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has complete procidentia of the uterus. Which of the following is the most appropriate next step in the management of this patient?

86) A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of something hanging out of her vagina. She had a hysterectomy for benign indications at age 48. For the past few months, she has been experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal opening. Two weeks ago something fell out of the vagina. On pelvic examination, the patient has total eversion of the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is the best next step in the management of this patient?

87) A 38-year-old woman presents to your office complaining of urinary incontinence. Her symptoms are suggestive of urge incontinence. She admits to drinking several large glasses of iced tea and water on a daily basis because her mother always told her to drink lots of liquids to lower her risk of bladder infections. Urinalysis and urine culture are negative. After confirming the diagnosis with physical examination and office cystometrics, which of the following treatments should you recommend to the patient as the next step in the management of her problem?

88) A 45-year-old woman with previously documented urge incontinence continues to be symptomatic after following your advice for conservative self-treatment. Which of the following is the best next step in management?

89) A 23-year-old G3POA2 female presents to your clinic at an estimated 12 weeks of gestational age. She is a new patient and has come to your clinic to seek an elective abortion. She has had two elective abortions in the past because of unplanned pregnancy. She has no past medical history and takes no medications. Her physical examination is within normal limits and a limited ultrasound examination was able to detect fetal heart tones. You and your partners have a strict policy against performing abortions because some members of the group object to the procedure. You decide it would be best to stick to this policy; however, the patient becomes angry and tells you that she will sue you if you do not perform the procedure. What is the best response to this patient?

90) A 24-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the physician complaining of aching and swelling in both legs. The aching of her legs is worst at night. She has no shortness of breath or chest pain. She has no past medical history. Her temperature is 36.9 C (98.2F), blood pressure is 110/70 mm Hg, and pulse is 78/min. Physical examination shows symmetrical pitting edema of both calves with no tenderness of either calf. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

91) A 32-year-old woman presents to your office with dysuria, urinary frequency, and urinary urgency for 24 hours. She is healthy but is allergic to sulfa drugs. Urinalysis shows large blood, leukocytes, and nitrites in her urine. Which of the following medications is the best to treat this patient’s condition?

92) You are seeing a patient in the emergency room who complains of fever, chills, flank pain, and blood in her urine. She has had severe nausea and started vomiting after the fever developed. She was diagnosed with a urinary tract infection 3 days ago by her primary care physician. The patient never took the antibiotics that she was prescribed because her symptoms improved after she started drinking cranberry juice. The patient has a temperature of 38.8C (102F). She has severe right-sided CVA tenderness. She has severe suprapubic tenderness. Her clean-catch urinalysis shows a large amount of ketones, RBCs, WBCs, bacteria, and squamous cells. Which of the following is the most appropriate next step in the management of this patient?

93) A 22-year-old woman has been seeing you for treatment of recurrent urinary tract infections over the past 6 months. She married 6 months ago and became sexually active at that time. She seems to become symptomatic shortly after having sexual intercourse. Which of the following is the most appropriate recommendation for this patient to help her with her problem?

94) A 17-year-old married girl comes to see you, complaining of “feeling tired all the time,” vomiting in the morning, and weight gain. Examination shows signs of pregnancy that is confirmed by laboratory studies. When informed of this, the girl is visibly distraught. “How could this happen?” she says, “I’ve been on the pill!” Mentioning that she and her husband live with her parents, she declares that she wants an immediate abortion. Which of the following is the best reply?

95) A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?

96) A 32-year-old woman, gravida 3, para 2, at 14 weeks' gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the "flu season" is coming, and she seems to get sick every year. Second, a child at her son's daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given?

97) A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5-centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management?

98) A 54-year-old female comes to the physician because of involuntary loss of urine. She states "Doc, whenever I laugh, cough, or sneeze, I am unable to hold my urine. I am afraid to leave the house." She has no involuntary loss of urine while sleeping. She had a hysterectomy four years ago. She has had no trauma to her head or back. She has no other medical problems and takes no medications. Physical examination shows a relaxed anterior vaginal wall. Neurological examination shows no abnormalities. A cotton-tipped swab test reveals a urethral straining angle of 45 degrees when intra-abdominal pressure is increased. Urinalysis shows no abnormalities. Which of the following is most beneficial long-term management for this patient?

99) A 32-year-old woman who is one week postpartum presents with dull pain in her left leg for the past three days. She denies any history of trauma, fever or chills. Her pregnancy and delivery were uncomplicated, and her past medical history is unremarkable. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/76 mm Hg. Physical examination reveals a swollen, tender, and mildly erythematous left leg. Doppler ultrasonogram reveals a thrombus in the superficial femoral vein of the left leg. Which of the following is the most appropriate next step in management?

100) A 26-year-old woman comes to the physician for a routine annual visit. She has no complaints. She has no significant previous medical problems. She has been sexually active since the age of 19 with the same partner. They married 4 years ago. She has never had any sexually transmitted diseases. She had her last Pap smear 4 years ago and was within normal limits. She does not use tobacco, alcohol or illicit drugs. Pelvic examination shows no abnormalities. A repeat Pap smear now shows atypical squamous cells of undetermined significance (ASC-US). Which of the following is the most appropriate next step in management?

101) A healthy 31-year-old G3P2002 patient presents to the obstetrician’s office at 34 weeks gestational age for a routine return visit. She has had an uneventful pregnancy to date. Her baseline blood pressures were 100 to 110/60 to70, and she has gained a total of 20 lb so far. During the visit, the patient complains of bilateral pedal edema that sometimes causes her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75. She denies any other symptoms or complaints. On physical examination, there is pitting edema of both legs without any calf tenderness. Which of the following is the most appropriate response to the patient’s concern?

102) A 25-year-old woman delivered a baby boy at 38 weeks gestation. The newborn has a small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. He weighs 2.5kg (5.51b). Further history or evaluation of the mother would most likely reveal which of the following?

103) A 19-year-old woman with a history of bipolar disorder and psychosis comes to the physician requesting a pregnancy test. Her last menstrual period was 2 months ago. Her menses usually occur every 30 days. She is sexually active with one partner and occasionally uses condoms. She is concerned because she has gained 3 kg (6lb) in the past 3 months. She also complains of breast tenderness and milky-white discharge from both nipples. She denies headaches, nausea, vomiting, diarrhea, and fever. Her vital signs are within normal limits. Physical examination shows no abnormalities. A urine pregnancy test is negative. Which of the following is most likely to be responsible for this patient's symptoms?

104) A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

105) A 43-year-old G1P0 who conceived via in vitro fertilization comes into the office for her routine OB visit at 38 weeks. She denies any problems since she was seen the week before. She reports good fetal movement and denies any leakage of fluid per vagina, vaginal bleeding, or regular uterine contractions. She reports that sometimes she feels crampy at the end of the day when she gets home from work, but this discomfort is alleviated with getting off her feet. The fundal height measurement is 36 cm; it measured 37 cm the week before. Her cervical examination is 2 cm dilated. Which of the following is the most appropriate next step in the management of this patient?

106) A 62-year-old woman comes to the physician because of vaginal itch and pain with intercourse. She had her last menstrual period at age 52. She has no medical problems, takes no medications, and is allergic to penicillin. Pelvic examination demonstrates pale vaginal mucosa with no rugae present. The vagina is dry with no discharge. A potassium hydroxide (KOH) and normal saline wet preparation is negative. Which of the following is the most appropriate initial step in management?

107) A 14-year-old phenotypically female child is brought to your office by her mother who is concerned that her daughter has not had menstrual bleeding yet. Her past medical history is significant for an episode of severe bilateral pneumonia that required hospitalization when she was seven years old. Physical examination reveals Tanner stage 3 breast development, but very little pubic and axillary hair. Bilateral inguinal masses are palpated. A blind vaginal pouch is noted on pelvic exam. A karyotype analysis showed 46 XY. Which of the following is the most appropriate next step in the management of this patient?

108) A 23-year-old primigravid woman comes to your office for her first prenatal visit. She is working as an aerobics instructor and is concerned about the effect her exercise schedule might have on the pregnancy. She teaches 30 minutes daily in the morning and does not feel fatigued. She does not use tobacco, alcohol or drugs. Vital signs are normal and physical examination is unremarkable. Which of the following is the best advice to give this patient?

109) A 27-year-old primigravid woman at 28 weeks gestation comes to the physician's office because she has not felt any fetal movements for the past 48 hours. Her pregnancy thus far has been uncomplicated. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She has no history of trauma. She has no history of serious illness. Review of systems reveals no abnormalities. She does not use tobacco, alcohol or drugs. Fetal heart tones are not heard by Doppler. Vital signs are normal. Which of the following is the most appropriate next step in management?

110) A 23-year-old female comes to your office to review her daily prescription medications. She had a positive pregnancy test three days ago despite strict contraception. Her last menstrual period was 5 weeks ago. She is on albuterol and beclomethasone inhalers for bronchial asthma, isotretinoin for acne, and lithium for bipolar disorder. Her bipolar disorder has been stable for the past several years. She does not use tobacco, alcohol, or drugs. Physical examination shows no abnormalities; vital signs are stable. Which of the following is the most appropriate advice for this patient?

111) A 28-year-old woman presents to her obstetrician for her first prenatal visit in November. She is at 8 weeks gestation as determined by her last menstrual period. She has no medical problems and takes no medications. She does not smoke cigarettes and stopped drinking alcohol when she decided to become pregnant. She has no history of illicit drug use and has never been diagnosed with a sexually transmitted disease. She has been in a monogamous relationship with her husband for the past one year. Her family history is unremarkable. Her BMI is 23 kg/m2. Her physical examination, including vital signs, is within normal limits. Which of the following preventive measures is warranted at this visit?

112) A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40 weeks gestational age by good dates and a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement; she has been doing kick counts for the past several days and reports that the baby moves about eight times an hour on average. On physical examination, her cervix is firm, posterior, 50% effaced, and 1 cm dilated, and the vertex is at a-1 station. As her obstetrician, which of the following should you recommend to the patient?

113) A 29-year-old G1P0 presents to the obstetrician’s office at 41 weeks gestation. On physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in position. The vertex is presenting at –3 station. Which of the following is the best next step in the management of this patient?

114) Your patient had an ultrasound examination today at 39 weeks gestation for size less than dates. The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5 centimeters. The patient’s cervix is unfavorable. Which of the following is the best next step in the management of this patient?

115) A healthy 30-year-old G1P0 at 41 weeks gestational age presents to labor and delivery at 11:00 PM because she is concerned that her baby has not been moving as much as normal for the past 24 hours. She denies any complications during the pregnancy. She denies any rupture of membranes, regular uterine contractions, or vaginal bleeding. On arrival to labor and delivery, her blood pressure is initially 140/90 but decreases with rest to 120/75. Her prenatal chart indicates that her baseline blood pressures are 100 to 120/60 to 70 mm Hg. The patient is placed on an external fetal monitor. The fetal heart rate baseline is 180 beats per minute with absent variability. There are uterine contractions every 3 minutes accompanied by late fetal heart rate decelerations. Physical examination indicates that the cervix is long/closed/-2. Which of the following is the appropriate plan of management for this patient?

116) A 27-year-old G3P2002, who is 34 weeks gestational age, calls the oncall obstetrician on a Saturday night at 10:00 PM complaining of decreased fetal movement. She says that yesterday her baby has moved only once per hour. For the past 6 hours she has felt no movement. She is healthy, has had regular prenatal care, and denies any complications so far during the pregnancy. Which of the following is the best advice for the on-call physician to give the patient?

117) You are seeing a patient in the hospital for decreased fetal movement at 36 weeks gestation. She is healthy and has had no prenatal complications. You order a BPP. The patient receives a score of 8 on the test. Two points were deducted for lack of fetal breathing movements. How should you counsel the patient regarding the results of the BPP?

118) A new patient presents to your office for her first prenatal visit. By her last menstrual period she is 11 weeks pregnant. This is the first pregnancy for this 36-year-old woman. She has no medical problems. At this visit you observe that her uterus is palpable midway between the pubic symphysis and the umbilicus. No fetal heart tones are audible with the Doppler stethoscope. Which of the following is the best next step in the management of this patient?

119) A healthy 30-year-old G2P1001 presents to the obstetrician’s office at 34 weeks for a routine prenatal visit. She has a history of a cesarean section (low transverse) performed secondary to fetal malpresentation (footling breech). This pregnancy, the patient has had an uncomplicated prenatal course. She tells her physician that she would like to undergo a trial of labor during this pregnancy. However, the patient is interested in permanent sterilization and wonders if it would be better to undergo another scheduled cesarean section so she can have a bilateral tubal ligation performed at the same time. Which of the following statements is true and should be relayed to the patient?

120) A 16-year-old primigravida presents to your office at 35 weeks gestation. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine. She has significant swelling of her face and extremities. She denies having contractions. Her cervix is closed and uneffaced. The baby is breech by bedside ultrasonography. She says the baby’s movements have decreased in the past 24 hours. Which of the following is the best next step in the management of this patient?

121) A 14-year-old girl comes to the physician because of lower abdominal cramping. This cramping starts a few hours before, and lasts through, her menses, and then resolves completely. The cramping is primarily in the lower abdomen but also radiates to the back and thighs. She first noted this cramping approximately 6 months after her first menstrual period at age 12. She is not sexually active. Physical examination is unremarkable, including a normal pelvic examination. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

122) A 20-year-old G1P0 presents to your clinic for follow-up for a suction dilation and curettage for an incomplete abortion. She is asymptomatic without any vaginal bleeding, fever, or chills. Her examination is normal. The pathology report reveals trophoblastic proliferation and hydropic degeneration with the absence of vasculature; no fetal tissue is identified. A chest x-ray is negative for any evidence of metastatic disease. Which of the following is the best next step in her management?

123) A 27-year-old G2P1 woman comes to the labor and delivery unit with nausea, vomiting, and right lower-quadrant pain. She is at 19 weeks gestation. The symptoms started 12 hours ago and have become progressively worse. She has no chills, dysuria, or urinary frequency and is uncertain if she has had a fever. Her temperature is 38 C (100.4 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 18/min. Abdominal examination shows a gravid uterus just below the umbilicus. The fetal heart rate is 144/min. There is moderate tenderness to palpation in the right lower quadrant with guarding. Laboratory results are as follows: Hemoglobin: 12.4 g/L, Leukocytes: 16,000/μL. Which of the following is the most appropriate next step in management of this patient?

124) A 19-year-old gravida 2, para 1 woman presents at her first prenatal visit complaining of a rash, hair loss, and spots on her tongue. Her temperature is 37 C (98.6 F), blood pressure is 112/74 mm Hg, pulse is 68/min, and respirations are 14/min. Physical examination is significant for a maculopapular rash on her trunk and extremities, including her palms and soles. She has "moth-eaten" alopecia and white patches on her tongue. Her uterus is 10 week size, which is consistent with her dating by last menstrual period. The rest of her examination is unremarkable. RPR and MHA-TP are positive. Which of the following is the most appropriate pharmacotherapy?

125) A 34-year-old woman with breast cancer presents to her physician complaining of increased weakness, lower back pain, and urinary incontinence. She was diagnosed with breast cancer 2 years ago and is undergoing radiation and chemotherapy. Her back pain developed 2 days ago. Physical examination shows lower extremity weakness and hyporeflexia. Which of the following is the most appropriate next step in this patient's care?

126) An 18-year-old woman presents to the physician's office complaining of vaginal pruritus and discharge. She has no nausea, vomiting, or abdominal pain. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no other medical problems and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72 mm Hg. Pelvic examination reveals mucopurulent cervical discharge and friable cervical mucosa. The remainder of the physical examination is unremarkable. A gram stain of the discharge reveals numerous polymorphonuclear leukocytes filled with gram-negative diplococci. What is the most appropriate next step in management?

127) A 30-year-old woman, gravida 3, para 2, at 32 weeks gestation comes to the physician because of a decrease in fetal movements. She has felt few fetal kicks the past 20 hours. Her prenatal course, prenatal tests and fetal growth have been normal. She has chronic hypertension and is now taking methyldopa and labetalol. Her previous pregnancies were uncomplicated and both delivered vaginally. She does not use tobacco, alcohol or drugs. Fetal heart tones are heard by Doppler. Non-stress test is reactive. Which of the following is the most appropriate next step in management?

128) A 34-year-old woman comes to the physician for infertility evaluation. Her cycles have been irregular for the past 12 months and she has had no periods for the past 3 months. Before that time, her cycles were quite regular. She also has hot flashes, dyspareunia, and mood disturbances. She has been married for 6 years and has a 3-year-old daughter. The patient has a history of Hashimoto's thyroiditis and is on thyroid replacement therapy. She smokes a pack of cigarettes a day. Both her father and mother have type 2 diabetes mellitus. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, serum prolactin is normal, and pregnancy test is negative. Serum TSH is within normal limits. Which of the following is the most appropriate treatment for her infertility?

129) A 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasound shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show: Serum fibrinogen level: 160 mg/dl (normal is 150 - 450 mg/dL), Platelets: 150, 000/mm3, Prothrombin time: 14 sec, Partial thromboplastin time: 28 sec, First trimester platelets were: 250,000/mm3. There are no signs of active bleeding. Which of the following is the most appropriate next step in management?

130) A 20-year old GOPO woman presents to the emergency room with complaints of vaginal bleeding and right lower quadrant pain. Her last menstrual period was approximately 5 weeks ago. She is sexually active and uses condoms occasionally. Her temperature is 37.2 C (98.9 F), blood pressure is 120/74 mm Hg, pulse is 80/min and respirations are 14/min. Examination shows mild right lower quadrant tenderness, but no rebound or guarding. There is no active vaginal bleeding and the cervical os is closed. Her initial hemoglobin is 11.0 g/dl. She is Rh positive and a quantitative β-HCG is 1000 mIU/mL. A vaginal ultrasound is done and no intrauterine or extrauterine pregnancy can be seen. Which of the following is next best step in management?

131) A 22-year-old primigravid woman comes for her initial prenatal visit at 6 weeks gestation. She has no complaints except mild nausea. She quit tobacco and alcohol use after she learned that she was pregnant. Vital signs are within normal limits. Physical examination shows no abnormalities. The screening VDRL test returns positive, as does the confirmatory FTA-ABS test. The patient has a history of an allergic reaction to penicillin. Which of the following is the best treatment for this patient?

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

133) A 24-year-old female presents to you for the evaluation of acne. Further questioning, reveals that she also has had irregular periods for a long time. She is single and not sexually active. On examination, her BMI is 31 Kg/m2 and she has evidence of hirsutism. Further evaluation reveals increase in serum free testosterone and LH/FSH ratio of 2.4. Glucose tolerance testing reveals two-hour blood glucose of 155 mg/dl. Apart from prescribing oral contraceptive pills, which of the following is indicated in this patient?

134) An 18-year-old woman presents to the physician's office complaining of vaginal pruritus and discharge. She has no nausea, vomiting, or abdominal pain. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no other medical problems and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72 mm Hg. Pelvic examination reveals mucopurulent cervical discharge and friable cervical mucosa. The remainder of the physical examination is unremarkable. A gram stain of the discharge reveals numerous polymorphonuclear lymphocytes filled with gram negative diplococci. What is the most appropriate next step in management?

135) A 55-year-old woman has a palpable 2 cm mass in her left breast. She had found the mass on self-examination, but she says that she had not done self-breast exam for at least six months before she did this one. Physical examination confirms the presence of the lesion, which is hard, movable, and not painful. A mammogram confirms the presence of an opacity in that area, but it does not have any of the radiological characteristics of a breast cancer. The radiologist also does a sonogram, and comes up with the same opinion, I.e., that neither study is suggestive for cancer. Fine needle aspirate is read as negative. Which of the following is the most appropriate next step in management?

136) A 19-year-old woman comes to the office because of irregular vaginal spotting. She always has had normal periods that occur every 28 days and last 5 days, and so this is particularly concerning. She is sexually active with her boyfriend of 3 years and has been taking oral contraceptive pills that you prescribed 2 months ago. She has no known medical problems besides seasonal allergies and has never had any surgery. She takes the oral contraceptive pill daily and loratadine intermittently, but takes no other medications. She has no known drug allergies. Physical examination, including pelvic examination, is unremarkable. Urine hCG is negative. Which of the following is the most appropriate next step in management?

137) A 38-year-old woman is 10 weeks pregnant with her second pregnancy and is found to have blood pressures exceeding the 150 to 160 mm Hg systolic range and 100 to 110mm Hg diastolic range at her first prenatal visit. She has no other medical problems. She had a cholecystectomy at the age of 20. She takes no medications and is allergic to sulfa drugs. Her family history is significant for hypertension on both her maternal and paternal sides. Physical examination is normal, including an obstetrical ultrasound demonstrating a 10-week intrauterine pregnancy. The patient is diagnosed with chronic hypertension. Which of the following should be used as first-line antihypertensive therapy for this patient?

138) A 20-year-old college student comes to the student health clinic concerned that she may be pregnant. She states that she has had a steady boyfriend for the last 2 years and that they regularly use condoms for birth control. Last night the condom broke, however, and the patient is extremely worried that she may have become pregnant. Although she has mixed feelings about terminating an advanced pregnancy, she is not opposed to terminating an early pregnancy, and wants to know if she can take an “abortion pill” that she has heard about in the news. Her last menstrual period was 14 days ago, and her last gynecologic examination, which included a negative Pap smear, was 10 months ago. She has no previous illnesses and has a negative review of systems. She does not smoke, drinks only rarely, and does not use any illicit substances. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 118/78 mmHg, pulse 72/min, and respirations 20/min. Physical examination is unremarkable. A urine pregnancy test is negative. Given her request, which of the following is the most appropriate management?

139) A 33-year-old woman is very depressed about her recurrent pregnancy loss. She has had four pregnancies that all have ended in spontaneous abortion before 8 weeks. Her past medical history is otherwise unremarkable. She has never had surgery. She takes acetaminophen occasionally for headaches, but otherwise uses no medications and has no known drug allergies. Physical examination is normal. Laboratory evaluation demonstrates that she is positive for lupus anticoagulant and that she is positive for anticardiolipin IgG. These results are again positive 8 weeks later. Which of the following is the most appropriate management of this patient during her next pregnancy?

140) A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management?

141) A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management?

142) A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management?

143) A 46-year-old woman presents to your office complaining of something bulging from her vagina for the past year. It has been getting progressively more prominent. She has started to notice that she leaks urine with laughing and sneezing. She still has periods regularly every 26 days. She is married. Her husband had a vasectomy for contraception. After appropriate evaluation, you diagnose a second-degree cystocele. She has no uterine prolapse or rectocele. Which of the following is the best treatment plan to offer this patient?

144) An 86-year-old woman presents to your office for her well-woman examination. She has no complaints. On pelvic examination performed in the supine and upright positions, the patient has second-degree prolapse of the uterus. Which of the following is the best next step in the management of this patient?

145) A 19-year-old primigravid woman at 42 weeks' gestation comes the labor and delivery ward for induction of labor. Her prenatal course was uncomplicated. Examination shows her cervix to be long, thick, closed, and posterior. The fetal heart rate is in the 140s and reactive. The fetus is vertex on ultrasound. Prostaglandin (PGE2) gel is placed intravaginally. One hour later, the patient begins having contractions lasting longer than 2 minutes. The fetal heart rate falls to the 70s. Which of the following is the most appropriate next step in management?

146) A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response?

147) A 21-year-old woman comes to the physician because of "bumps" on her vulva that she has just recently noticed. These bumps do not cause her symptoms, but she wants to know what they are and wants them removed. She has no medical problems, takes no medications, and has no allergies to medications. She smokes one-half pack of cigarettes per day. She is sexually active with 3 partners. Examination shows 3 cauliflower-like lesions on the right labia majora. Which of the following is the most appropriate next step in management?

148) A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F), blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values are as follows: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L, and ALT 300 U/L. Which of the following is the most appropriate next step in management?

149) A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her prenatal course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid, bleeding, or contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient states that a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery and wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the following is the most appropriate response?

150) A 32-year-old nulliparous woman at 38 weeks' gestation comes to the labor and delivery ward with regular painful contractions after a gush of fluid two hours ago. Her temperature is 98.6 F (37 C). She is found to have gross rupture of membranes and to have a cervix that is 6 centimeters dilated. The fetus is in breech position. The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration?

151) A 21-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with painful contractions every three minutes. Her prenatal course was unremarkable. Examination shows her cervix to be 3 centimeters dilated and 90% effaced. The fetal heart rate tracing is in the 150s and reactive. 5 hours later cervical examination reveals that the patient is 9 centimeters dilated and at -1 station. The fetal heart rate tracing shows moderate variable decelerations with each contraction and decreased variability. Fetal scalp sampling is performed that yields fetal scalp pH of 7.04, 7.05, and 7.06. Which of the following is the most appropriate next step in management?

152) A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout the pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental illness. She states that she has been weighing the benefits and risks of cesarean delivery in preventing transmission of the virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery and would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management?

153) An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually active since the age of 15 and has had numerous sexual partners since that time. She has tried the oral contraceptive pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has had gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable. Which of the following forms of birth control should be recommended for this patient?

154) A pharmaceutical company sponsors a physician lecture concerning thrombotic complications of the oral contraceptive pill (OCP). At the start of the presentation, the company's representative makes a short presentation regarding their particular brand of OCP. He then proceeds to announce that his company would like to award a gift to the physician in the group who gives the largest number of prescriptions for this pill. Which of the following is the most appropriate action?

155) A 24-year old woman comes to the physician because of burning with urination. She states that every time she urinates there is pain and that she has a feeling that she constantly needs to urinate even though only a little comes out. She has never had any similar symptoms before. She has no medical problems and no known drug allergies. Examination is unremarkable. Urinalysis demonstrates that the urine is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate pharmacotherapy?

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

157) A 32-year-old G2P0101 presents to labor and delivery at 34 weeks of gestation, complaining of regular uterine contractions about every 5 minutes for the past several hours. She has also noticed the passage of a clear fluid per vagina. A nurse places the patient on an external fetal monitor and calls you to evaluate her status. The external fetal monitor demonstrates a reactive fetal heart rate tracing, with regular uterine contractions occurring about every 3 to 4 minutes. On sterile speculum examination, the cervix is visually closed. A sample of pooled amniotic fluid seen in the vaginal vault is fern and nitrazine-positive. The patient has a temperature of 38.8C, pulse 102 beats per minute, blood pressure 100/60 mm Hg, and her fundus is tender to deep palpation. Her admission blood work comes back indicating a WBC of 19,000. The patient is very concerned because she had previously delivered a baby at 35 weeks who suffered from respiratory distress syndrome (RDS). You perform a bedside sonogram, which indicates oligohydramnios and a fetus whose size is appropriate for gestational age and with a cephalic presentation. Which of the following is the most appropriate next step in the management of this patient?

158) A 30-year-old G1 with twin gestation at 28 weeks is being evaluated for vaginal bleeding and uterine contractions. A bedside ultrasound examination rules out the presence of a placenta previa. Fetal heart rate tracing is reactive on both twins, and the uterine contractions are every 2 to 3 minutes and last 60 seconds. A sterile speculum examination is negative for rupture membranes. A digital examination indicates that the cervix is 2 to 3 cm dilated and 50% effaced, and the presenting part is at −3 station. Tocolysis with magnesium sulfate is initiated and intravenous antibiotics are started for group B streptococcus prophylaxis. Betamethasone, a corticosteroid, is also administered. Which of the following statements regarding the use of betamethasone in the treatment of preterm labor is true?

159) A 30-year-old G1 at 28 weeks gestation with a twin pregnancy is admitted to the hospital for preterm labor with regular painful contractions every 2 minutes. She is 3 cm dilated with membranes intact and a small amount of bloody show. Ultrasound reveals growth restriction of twin A and oligohydramnios, otherwise normal anatomy. Twin B has normal anatomy and has appropriate-for-gestational-age weight. Which of the following is a contraindication to the use of indomethacin as a tocolytic in this patient?

160) A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa presents to the hospital with vaginal bleeding. On assessment, she has normal vital signs and the fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. No uterine contractions are demonstrated on external tocometer. Heavy vaginal bleeding is noted. Which of the following is the best next step in the management of this patient?

161) A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa is admitted to the hospital for vaginal bleeding. The patient continues to bleed heavily and you observe persistent late decelerations on the fetal heart monitor with loss of variability in the baseline. Her blood pressure and pulse are normal. You explain to the patient that she needs to be delivered. The patient is delivered by cesarean section under general anesthesia. The baby and placenta are easily delivered, but the uterus is noted to be boggy and atonic despite intravenous infusion of Pitocin. Which of the following is contraindicated in this patient for the treatment of uterine atony?