DES 2016. Final (Part 42)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

292) You are following a 22-year-old G2P1 at 39 weeks during her labor. She is given an epidural for pain management. Three hours after administrating the pain medication, the patient’s cervical examination is unchanged. Her contractions are now every 2 to 3 minutes, lasting 60 seconds. The fetal heart rate tracing is 120 beats per minute with accelerations and early decelerations. Which of the following is the best next step in management of this patient?

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

294) You are delivering a 26-year-old G3P2002 at 40 weeks. She has a history of two previous uncomplicated vaginal deliveries and has had no complications this pregnancy. After 15 minutes of pushing, the baby’s head delivers spontaneously, but then retracts back against the perineum. As you apply gentle downward traction to the head, the baby’s anterior shoulder fails to deliver. Which of the following is the best next step in the management of this patient?

295) A 41-year-old G1P0 at 39 weeks, who has been completely dilated and pushing for 3 hours, has an epidural in place and remains undelivered. She is exhausted and crying and tells you that she can no longer push. Her temperature is 38.3C (101F). The fetal heart rate is in the 190s with decreased variability. The patient’s membranes have been ruptured for over 24 hours, and she has been receiving intravenous penicillin for a history of colonization with group B streptococcus bacteria. The patient’s cervix is completely dilated and effaced and the fetal head is in the direct OA position and is visible at the introitus between pushes. Extensive caput is noted, but the fetal bones are at the +3 station. Which of the following is the most appropriate next step in the management of this patient?

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

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

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

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

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

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

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

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

304) A 21-year-old G2P2 calls her physician 7 days postpartum because she is concerned that she is still bleeding from the vagina. She describes the bleeding as light pink to bright red and less heavy than the first few days postdelivery. She denies fever or any cramping pain. On examination she is afebrile and has an appropriately sized, nontender uterus. The vagina contains about 10 cc of old, dark blood. The cervix is closed. Which of the following is the most appropriate treatment?

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

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

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

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

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

310) You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant?

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

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

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

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

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

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

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

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

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

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

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

322) A 42-year-old G4P3104 presents for her well-woman examination. She has had three vaginal deliveries and one cesarean delivery for breech. She states her cycles are regular and denies any sexually transmitted diseases. Currently she and her husband use condoms, but they hate the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. She drinks and smokes socially. She weighs 78 kg, and her blood pressure is 142/89 mm Hg. During her office visit, you counsel the patient at length regarding birth control methods. Which of the following is the most appropriate contraceptive method for this patient?

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

324) A 32-year-old female presents for her yearly examination. She has been smoking one pack of cigarettes a day for the past 12 years. She wants to stop, and you make some recommendations to her. Which of the following is true regarding smoking cessation in women?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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