Part 54

26) Five patients present for contraceptive counseling, each requesting that an IUD be inserted. Which of the following is a recognized contraindication to the insertion of an IUD?

27) A 30-year-old woman presents to your office for her well-woman examination and contraception. She has two prior vaginal deliveries without any complications. Her medical and surgical histories are negative. Her family history is significant for coronary heart disease in her father and breast cancer in her mother diagnosed at the age of 62 years. In addition to effective contraception, health benefits for women taking oral combination contraceptives include which of the following?

28) A couple presents to your office to discuss permanent sterilization. They have three children and are sure they do not want any more. You discuss the risk and benefits of surgical sterilization. Which of the following statements is true regarding surgical sterilizations?

29) A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response?

30) The shortest distance between the sacral promontory and the symphysis pubis is called which of the following?

31) A patient presents in labor at term. Clinical pelvimetry is performed. She has an oval-shaped pelvis with the anteroposterior diameter at the pelvic inlet greater than the transverse diameter. The baby is occiput posterior. The patient most likely has what kind of pelvis?

32) On pelvic examination of a patient in labor at 34 weeks, the patient is noted to be 6 cm dilated, completely effaced with the fetal nose and mouth palpable. The chin is pointing toward the maternal left hip. This is an example of which of the following?

33) A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?

34) A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucus and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?

35) A 32-year-old poorly controlled diabetic G2P1 is undergoing amniocentesis at 38 weeks for fetal lung maturity prior to having a repeat cesarean section. Which of the following laboratory tests results on the amniotic fluid would best indicate that the fetal lungs are mature?

36) A wealthy executive donates five million dollars for the prevention of intrauterine growth restriction in the local county. Spending this money on which of the following programs would prevent the greatest number of cases of fetal growth restriction (FGR) in the population?

37) Your patient is a healthy 28-year-old G2P1001 at 20 weeks gestational age. Two years ago, she vaginally delivered at term a healthy baby boy weighing 6 lb 8 oz. This pregnancy, she had a prepregnancy weight of 130 lb. She is 5ft 4 in tall. She now weighs 140 lb and is extremely nervous that she is gaining too much weight. She is worried that the baby will be too big and require her to have a cesarean section. What is the best counsel for this patient?

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

39) A 62-year-old postmenopausal woman was found to have right adnexal enlargement on pelvic examination 2 weeks ago. Transabdominal and transvaginal ultrasounds revealed a 5-cm, unilocular, right ovarian mass with regular borders. There is no ascites. The patient went through menopause at age 52. She has had no postmenopausal spotting. There is no family history of ovarian or breast cancer. Her latest mammogram 2 months ago showed no abnormalities. Which of the following is the most appropriate course of action?

40) A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucous and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?

41) A 21-year-old nulligravid woman comes to her physician to discuss birth control options. She became sexually active for the first time 2 weeks ago. She is currently using condoms for contraception. Her past medical history is significant for asthma, which has been inactive for 2 years. She takes no medications and has no allergies to medications. She has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next 6 years. She now has most significantly decreased her risk of developing which of the following malignancies?

42) A 33-year-old, gravida 3, para 3 woman comes to the physician because of amenorrhea of 9-month duration. She denies symptoms of any kind. She had a tubal ligation after the birth of her last child 2 years ago. She did not breast feed. Her menarche was at the age of 13 years, and her menses were regular until 18 months ago. At that time, her menses skipped every other month, and then they stopped. She currently takes no medication. She weighs 120.2 kg (264lb) and is 160 cm (5'3") tall. Initial physical examination shows no abnormalities except for morbid obesity. In the initial blood work, serum TSH and prolactin levels are within normal limits. Follow-up laboratory test show: FSH 20 mIU/mL (normal: 5-30 mIU/mL), LH 15 mIU/mL (normal: 5-20 mIU/mL). Which of the following is the most likely explanation for this patient's amenorrhea?

43) An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient’s estimated date of delivery?

44) A 45-year-old white female has undergone a right mastectomy for a node-negative, estrogen and progesterone receptor-positive tumor. She is scheduled to begin adjuvant therapy with tamoxifen. Her menstrual cycles are regular and her last menstrual period was 15 days ago. She has many concerns about tamoxifen therapy and would like to know its risks and benefits. Which of the following is she at risk for?

45) A 14-year-old girl s brought to the physician's office because of irregular menstrual periods. She had her menarche at age 13, and since then her periods have been irregular with the cycles varying from 3 to 6 weeks. She has no other symptoms. Physical examination is unremarkable. She has age appropriate secondary sexual characters. A urine pregnancy test is negative. Serum prolactin and thyroid stimulating hormone levels are normal. Administration of micronized oral progesterone results in withdrawal bleeding in 3 days. Which of the following most likely explains her irregular periods?

46) A 26-year-old woman comes to the physician for follow-up after a recent spontaneous abortion at 14 weeks gestation. She had one other spontaneous first trimester abortion two years ago. She has no other medical problems and does not use tobacco, alcohol or drugs. Review of systems reveals photosensitivity and occasional hematuria. On examination, you observe a bilateral malar rash. What is the most likely pathophysiology for her abortions?

47) A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery?

48) A 29-year-old patient comes to the physician for an annual examination. She has normal menstrual periods every 30 days. She was 15 years old when she first began having intercourse. She uses condoms for contraception. Her past medical history is significant for multiple sclerosis. This condition has required her to use a wheelchair for the past 4 years, which makes pelvic examination somewhat difficult for her. She smokes one pack of cigarettes per day. Given her difficulty with the pelvic examination, she inquires as to how often she needs to have a Pap smear performed. Which of the following is the correct answer?

49) A 33-year-old woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no medical problems and takes no medications. She has no family history of congenital anomalies. Her husband is 55 years old. He is in good health and also has no family history of birth defects. The patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know the paternal age above which amniocentesis or chorionic villus sampling should be considered. Which of the following is the correct response?

50) A 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-week-sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following?

51) A maternal fetal medicine specialist is consulted and performs an in-depth sonogram on a 30-year-old G1 at 28 weeks with a twin gestation. The sonogram indicates that the fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. Which of the following would be a finding most likely associated with twin A?

52) A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had a normal vaginal delivery at 40 weeks and the baby weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a nonsmoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100 to 120/60 to 70. During her examination, you note that her fundal height measures only 25 cm. Which of the following is a likely explanation for this patient’s decreased fundal height?

53) A 38-year-old G4P3 at 33 weeks gestation is noted to have a fundal height of 29 cm on routine obstetrical visit. An ultrasound is performed by the maternal-fetal medicine specialist. The estimated fetal weight is determined to be in the fifth percentile for the estimated gestational age. The biparietal diameter and abdominal circumference are concordant in size. Which of the following is associated with symmetric growth restriction?

54) A 37-year-old G4P2 presents to your office for new OB visit at 8 weeks. In a prior pregnancy, the fetus had multiple congenital anomalies consistent with trisomy 18, and the baby died shortly after birth. The mother is worried that the current pregnancy will end the same way, and she wants testing performed to see whether this baby is affected. Which of the following can be used for chromosome analysis of the fetus?

55) A 21-year-old G0 woman presents for a well-woman examination. Menarche began at age 12 years, and her periods occur every 26–30 days and last 4–5 days. She has had two sexual partners since becoming sexually active last year. She uses condoms for contraception and denies a history of sexually transmitted disease. Her physical examination is within normal limits. She has never had a pelvic exam before, and asks why it is necessary for her to get a Pap smear. Which of the following statements about cervical cancer screening is true?

56) During routine breast examination of a 28-year-old woman with no significant family or past medical history, a firm 2-cm mass is detected in the patient’s right breast. It is freely mobile and non-tender. Ultrasound reveals a solid, well-circumscribed mass, which is later found to be benign by biopsy. Which of the following statements is true?

57) Labor and vaginal delivery occur successfully in a 29-year-old woman after administration of oxytocin (Pitocin) for 9 hours. Spontaneous onset of labor at term is the result of which of the following?

58) A 28-year-old woman with 28-day menstrual cycle is attempting to conceive and is considering the use of a home ovulation predictor kit to time intercourse at ovulation. She asks you what day of her menstrual cycle her luteinizing hormone (LH) peak is most likely to occur. What should you tell her?

59) An 11-year-old girl has her first menses. Both ovaries contain approximately how many oocytes?

60) A healthy 29-year-old gravida 2 woman at 39 weeks has been in labor for 3 hours. She had a positive vaginal-anal culture for GBS at 37 weeks’ gestation. Which one of the following statements is correct?

61) A 17-year-old woman, gravida 1, para 0, at 38 weeks' gestation comes to the labor and delivery ward because of contractions. Her dating was determined by a 7-week ultrasound. Her prenatal course was complicated by gestational diabetes. Her past surgical history is significant for shoulder surgery. She takes insulin and prenatal vitamins. She has no known drug allergies. She smokes 3-4 cigarettes per day. She is initially found to be 4 cm dilated and is contracting every 2-3 minutes. She is admitted to the labor and delivery ward and, over the next 4 hours, progresses to full dilation. After pushing for 2 hours, she delivers the fetal head but has great difficulty delivering the fetal shoulders. Eventually, the fetus is delivered by the posterior arm. In the process of delivery of the newborn's humerus is fractured. Which of the following factors contributed the most to the difficult delivery of the fetus?

62) A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test: Negative, Free T4: 2.5 μg/dl (N= 5-12), Serum TSH: 11 .0 μU/ml (N= 0.5-5.0), Prolactin: 30 ng/ml (< 20 ng/ml). Antimicrosomal antibodies: Positive of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?

63) A 51-year-old woman comes to your office for a routine health maintenance examination. She has no medical history but states that she has been having irregular menses and occasional hot flashes for the past eight months. Her husband has told her that she appears moody all the time. She has not had any surgeries in the past and currently takes no medications. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but she does drink four to five twelve-ounce beers a day for the past 20 years to relieve her stress. She is a lacto-ovo vegetarian and walks two miles on a treadmill each day. Her temperature is 36.5C (97.7F), blood pressure is 120/70, heart rate is 84 beats/minute, and respirations are 12/minute. She is 5'4" and weighs 180 pounds (BMI is 30.9 kg/m2). Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?

64) A 25-year-old woman comes to the physician with abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms intermittently in 7 to 10-day episodes. In retrospect, she is unable to identify any triggers for her symptoms. The patient has a history of postpartum depression but has no recent feelings of hopelessness or guilt Physical examination is normal. Complete blood count, serum chemistries, and thyroid-stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management of this patient?

65) A 25-year-old woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she has had nausea and vomiting for five weeks. She is sexually active. Her medical and obstetrical histories are unremarkable. Serum hCG level is elevated. Which of the following is the most important role of hCG in pregnancy?

66) Your patient delivers a 7-lb 0-oz male infant at term. On physical examination, the baby has normal-appearing male external genitalia. However, the scrotum is empty. No testes are palpable in the inguinal canals. At 6 months of age the boy’s testes still have not descended. A pelvic ultrasound shows the testes in the pelvis, and there appears to be a uterus present as well. The presence of a uterus in an otherwise phenotypically normal male is owing to which of the following?

67) A 20-year-old female with Müllerian agenesis is undergoing laparoscopic appendectomy by a general surgeon. You are consulted intraoperatively because the surgeon sees several lesions in the pelvis suspicious for endometriosis. You should tell the surgeon which of the following?

68) A 19-year-old patient presents to your office with primary amenorrhea. She has normal breast and pubic hair development, but the uterus and vagina are absent. Diagnostic possibilities include which of the following?

69) Which of the following pubertal events in girls is not estrogen dependent?

70) A 9-year-old girl has breast and pubic hair development. Evaluation demonstrates a pubertal response to a GnRH-stimulation test and a prominent increase in luteinizing hormone (LH) pulses during sleep. These findings are characteristic of patients with which of the following?

71) You suspect that your infertility patient has an inadequate luteal phase. She should undergo an endometrial biopsy on which day of her menstrual cycle?

72) You have recommended a postcoital test for your patient as part of her evaluation for infertility. She and her spouse should have sexual intercourse on which day of her menstrual cycle as part of postcoital testing?

73) You ask a patient to call your office during her next menstrual cycle to schedule a hysterosalpingogram as part of her infertility evaluation. Which day of the menstrual cycle is best for performing the hysterosalpingogram?

74) You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked. Which is the best day of the menstrual cycle to check her progesterone level if you are trying to confirm ovulation?

75) Your patient is 43 years old and is concerned that she may be too close to menopause to get pregnant. You recommend that her gonadotropin levels be tested. Which is the best day of the menstrual cycle to check gonadotropin levels in this situation?

76) A 28-year-old woman comes to your office for an annual visit. She has been in good health over the past year. She exercises regularly and watches her diet. She has hypothyroidism for which she takes thyroid hormone replacement. She has no other medical problems. She had an appendectomy at the age of 18 and has had no other surgeries. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exam, is normal. She has three children and does not wish to become pregnant again. She has tried the oral contraceptive pill and the intrauterine device (IUD), but stopped both of these methods because of side effects. She is now considering tubal ligation. Counseling of this patient should include the fact that if she does have a tubal ligation she will be at increased risk for which of the following conditions?

77) A 56-year-old woman presents to your office for her routine wellwoman examination. She had a hysterectomy at age 44 for symptomatic uterine fibroids. She entered menopause at age 54 based on menopausal symptoms and an elevated FSH level. She started taking estrogen replacement therapy at that time for relief of her symptoms. She is fasting and would like to have her lipid panel checked while she is in the office today. You counsel the patient on the effects of estrogen therapy on her lipid panel. She should expect which of the following?

78) A 65-year-old woman presents to your office for evaluation of genital prolapse. She has a history of chronic hypertension, well controlled with a calcium channel blocker. She has had three full-term spontaneous vaginal deliveries. The last baby weighed 9 lb and required forceps to deliver the head. She says she had a large tear in the vagina involving the rectum during the last delivery. She has a history of chronic constipation and often uses a laxative to help her have a bowel movement. She has smoked for more than 30 years and has a smoker’s cough. She entered menopause at age 52 but has never taken hormone replacement therapy. Which of the following factors is least important in the subsequent development of genital prolapse in this patient?

79) A 31-year-old primigravid woman comes to the physician for a prenatal visit. She is known to be HIV positive. She also has asthma, for which she uses an inhaler. She had a diagnostic laparoscopy at age 20 for pelvic pain and has had no other surgeries. She has no known drug allergies. Extensive counseling is given to the patient regarding vertical transmission of HIV to the fetus. It is recommended to her that she take antiretroviral therapy during the pregnancy to decrease the vertical transmission rate. It is also recommended to her that she have a scheduled cesarean delivery. After consideration of these options, the patient chooses not to take the antiretrovirals and opts for a vaginal delivery. Which of the following represents the approximate risk of vertical transmission (from the mother to the fetus) for this patient?

80) A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit. She feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal course has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She has many questions regarding the procedure, including whether there is a risk of failure. Which of the following represents the closest estimate for the likelihood of failure of a postpartum tubal ligation?

81) A 23-year-old primigravid woman at 29-weeks' gestation comes to the physician because of contractions. She states that they have been occurring every 3-5 minutes for the past few hours and that they are worsening in intensity. Examination reveals that the patient is afebrile and her abdomen is nontender. Her cervix is 3 cm dilated, and the fetus is in vertex position. The patient is started on IV magnesium sulfate and penicillin and given an intramuscular injection of betamethasone. Which of the following represents the most significant consequence of this patient's preterm labor?

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

83) A 22-year-old has just been diagnosed with toxoplasmosis. You try to determine what her risk factors were. The highest risk association is which of the following?

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

85) A 37-year-old G3P2 presents to your office for her first OB visit at 10 weeks gestation. She has a history of Graves’ disease and has been maintained on propylthiouracil (PTU) as treatment for her hyperthyroidism. She is currently euthyroid but asks you if her condition poses any problems for the pregnancy. Which of the following statements should be included in your counseling session with the patient?

86) A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 2 to 10 minutes. The nurse states that the contractions are mild to palpation. On examination the cervix is 2 cm dilated, 50% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Which of the following stages of labor is this patient in?

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

88) A 26-year-old G1P1 is now postoperative day (POD) 6 after a low transverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 39C (102.2F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with firm, nontender uterus below the umbilicus. On pelvic examination her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative. Which of the following statements is true regarding this patient’s condition?

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

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