1031 OGYNEO bong CN part 2 (410-515 ) GD

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?

A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year ago. Over the past year, she has noted a persistence of her hot flashes, which come several times each day and are associated with a feeling of heat and flushing. They also awaken her at night and interfere with her sleep. She has no medical problems, takes no medications, and has no known drug allergies. She has a family history of cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started on estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to decrease her risk of which of the following?

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?

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?

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?

A 14-year-old girl comes to the physician for an annual examination. She has no complaints. She became sexually active during the past year and uses condoms occasionally for contraception. She has asthma, for which she occasionally takes an albuterol inhaler. She had an appendectomy at age 9. Physical examination is unremarkable including a normal pelvic examination. When should this patient begin having Pap testing?

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?

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?

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?

A previously healthy 21-year-old woman has a profuse, malodorous vaginal discharge. Examination shows a greenish gray "frothy" discharge with a "fishy" odor and petechial lesions on the cervix. There is no cervical motion tenderness. Her temperature is 37.5 C (99.4 F), blood pressure is 120/80 mm Hg, pulse is 60/min, and respirations are 16/min. Microscopic evaluation of the discharge is most likely to show which of the following?

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 pHs of 7.04, 7.05, and 7.06. Which of the following is the most appropriate next step in management?

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?

A 26-year-old nulligravid woman comes to the emergency department because of severe right lower quadrant pain. She states that the pain started last night. This morning she was awakened from sleep with severe pain in the same area. During the episode of pain, she also had nausea, vomiting, and diaphoresis. On admission to the emergency department she required 5 mg of morphine to control her pain. Examination is significant for right lower quadrant tenderness and a tender right adnexal mass on pelvic examination. Urine hCG is negative. Urinalysis is negative. Transvaginal ultrasound reveals an 8 cm right ovarian mass. Which of the following is the most likely diagnosis?

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?

425. 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?

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?

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?

A 21-year-old woman comes to the physician because of abdominal pain. She states that the pain is in her right lower quadrant and has been getting worse over the past 3 months. She has no other symptoms and a normal appetite. Examination demonstrates mild right lower quadrant abdominal tenderness. Pelvic examination reveals mild right adnexal enlargement and tenderness. Urine human chorionic gonadotropin (hCG) is negative. A pelvic ultrasound is obtained that shows a 4-centimeter, heterogeneous hyperechoic lesion in the right adnexa with cystic areas. On transvaginal ultrasound, hair and calcifications are demonstrated within the cystic areas. Which of the following is the most likely diagnosis?

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?

A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy?

A18-year-old G1 at 8 weeks gestation complains of nausea and vomiting over the past week occurring on a daily basis. Nausea and emesis are a common symptom in early pregnancy. Which of the following signs or symptoms would indicate a more serious diagnosis of hyperemesis gravidarum?

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?

A 30-year-old G1P0 with a twin gestation at 25 weeks presents to labor and delivery complaining of irregular uterine contractions and back pain. She reports an increase in the amount of her vaginal discharge, but denies any rupture of membranes. She reports that earlier in the day she had some very light vaginal bleeding, which has now resolved. On arrival to labor and delivery, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 minutes. She is afebrile and her vital signs are all normal. Her gravid uterus is non tender. The nurses call you to evaluate the patient. Which of the following is the most appropriate first step in the evaluation of vaginal bleeding in this patient?

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?

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?

436. 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?

Healthy 42-year-old G2P1001 presents to labor and delivery at 30 weeks gestation complaining of a small amount of bright red blood per vagina which occurred shortly after intercourse. It started off as spotting and then progressed to a light bleeding. By the time the patient arrived at labor and delivery, the bleeding had completely resolved. The patient denies any regular uterine contractions, but admits to occasional abdominal cramping. She reports no pregnancy complications and a normal ultrasound done at 14 weeks of gestation. Her obstetrical history is significant for a previous low transverse cesarean section at term. Which of the following can be ruled out as a cause for her vaginal bleeding?

34-year-old G2P1 at 31 weeks gestation presents to labor and delivery with complaints of vaginal bleeding earlier in the day that resolved on its own. She denies any leakage of fluid or uterine contractions. She reports good fetal movement. In her last pregnancy, she had a low transverse cesarean delivery for breech presentation at term. She denies any medical problems. Her vital signs are normal and electronic external monitoring reveals a reactive fetal heart rate tracing and no uterine contractions. Which of the following is the most appropriate next step in the management of this patient?

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?

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?

A 20-year-old G1P0 at 30 weeks gestation with a known placenta previa is delivered by cesarean section under general anesthesia for vaginal bleeding and nonreassuring fetal heart rate tracing. The baby is easily delivered, but the placenta is adherent to the uterus and cannot be completely removed, and heavy uterine bleeding is noted. Which of the following is the best next step in the management of this patient?

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?

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?

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?

A 26-year-old G1 at 37 weeks presents to the hospital in active labor. She has no medical problems and has a normal prenatal course except for fetal growth restriction. She undergoes an uncomplicated vaginal delivery of a female infant weighing 1950 g. The infant is at risk for which of the following complications?

A 38-year-old G1P1 comes to see you for her first prenatal visit at 10 weeks gestational age. She had a previous term vaginal delivery without any complications. You detect fetal heart tones at this visit, and her uterine size is consistent with dates. You also draw her prenatal labs at this visit and tell her to follow up in 4 weeks for a return OB visit. Two weeks later, the results of the patient’s prenatal labs come back. Her blood type is A–, with an anti-D antibody titer of 1:4. Which of the following is the most appropriate next step in the management of this patient?

A 23-year-old G3P1011 at 6 weeks presents for routine prenatal care. She had a cesarean delivery 3 years ago for breech presentation after a failed external cephalic version. Her daughter is Rh-negative. She also had an elective termination of pregnancy 1 year ago. She is Rh-negative and is found to have a positive anti-D titer of 1:8 on routine prenatal labs. Failure to administer RhoGAM at which time is the most likely cause of her sensitization?

A 27-year-old G2P1 at 29 weeks gestational age, who is being followed for Rh isoimmunization presents for her OB visit. The fundal height is noted to be 33 cm. An ultrasound reveals fetal ascites and a pericardial effusion. Which of the following can be another finding in fetal hydrops?

A 39-year-old G1P0 at 39 weeks gestational age is sent to labor and delivery from her obstetrician’s office because of a blood pressure reading of 150/100 mm Hg obtained during a routine OB visit. Her baseline blood pressures during the pregnancy were 100 to 120/60 to 70. On arrival to labor and delivery, the patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. The heart rate strip is reactive and the tocodynamometer indicates irregular uterine contractions. The patient’s cervix is 3 cm dilated. Her repeat blood pressure is 160/90 mm Hg. Hematocrit is 34.0, platelets are 160,000, SGOT is 22, SGPT is 15, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

A 21-year-old woman presents to the clinic in tears. She states that she recently found out she was pregnant at 10 weeks’ gestation. She is a recovering alcoholic but recently relapsed, consuming several drinks a day. She is nervous about the effects of her drinking on her fetus. For which of the following is the patient at greatest risk?

A 28-year-old G1P0 woman at 12 weeks’ gestation presents for routine follow-up with her obstetrician. She complains of mild nausea and occasional vomiting, but otherwise is doing well and reports no other symptoms or complications. Her physical examination is unremarkable and fetal ultrasound is normal for gestational age. Laboratory tests show: Free triiodothyronine: 180 ng/dL Free thyroxine: 2.2 ng/dL Total thyroxine: 12 μg/dL Thyroid-stimulating hormone: 0.1 μU/mL (normal: 0.4–4 μU/mL) Results of a thyroid-stimulating hormone receptor antibody test are negative. Which of the following best explains these findings?

A 27-year-old G1P0 woman at 27 weeks’ gestation presents to the emergency department after a motor vehicle accident. The patient denies any abdominal pain or cramping, contractions, or vaginal bleeding. Examination reveals a gravid, non-tender abdomen and a closed, non- effaced cervix with no evidence of vaginal bleeding. Fetal heart monitoring shows a fetal heart rate of 145/min, with variable accelerations and no decelerations. The patient is Rh negative with no history of blood transfusion, while the father is of unknown Rh status and unavailable. The results of the Kleihauer-Betke test, in which maternal blood is exposed to acid, shows a combination of pale and stained RBCs. Which of the following is the best next step in management?

A 27-year-old G1 woman is 20 weeks pregnant. She is currently in her third year of a family practice residency and would like to travel to Africa and Asia as part of an outreach mission with her program. She has received all of her childhood immunizations. She presents to the obstetric clinic inquiring about the safety of immunizations during pregnancy. Which of the following vaccines is contraindicated in pregnancy?

A 28-year-old G0 woman presents to the clinic complaining of inability to conceive and amenorrhea. She has been taking a low-dose oral contraceptive pill for the past 6 years, which she discontinued 3 months ago when she and her husband decided they wanted to have children. They have been sexually active with each other two to three times per week over the past 3 months, but the patient has not become pregnant. The patient denies a history of sexually transmitted disease and states that until recently she has always had regular menstrual cycles. She has not had a period since discontinuation of the oral contraceptive. Which of the following is the most appropriate next step?

A 31-year-old G3P2 woman at 37 weeks’ gestation presents to the labor and delivery floor after 2 hours of contractions of increasing frequency and intensity. An epidural anesthetic is requested on admission and placed. The patient continues to have contractions for the next 15 hours, during which time her membranes rupture spontaneously. Vaginal examination at that time reveals a cervix that is soft, 3 cm dilated, in an anterior position, and 80% effaced. The fetal head is at the -1 station. Fetal heart tracings reveal a baseline heart rate of 156/min, with variable accelerations and no significant decelerations. Which of the following is the best next step in management?

A 24-year-old G2P2 woman presents to the emergency department complaining of vaginal bleeding and abdominal cramping. She is sexually active in a monogamous relationship with her husband. Her last menstrual period was 6 weeks ago. The patient is afebrile, and vital signs are within normal limits. Pelvic examination is notable for a dilated cervix, fetal tissue in the vaginal vault, and no cervical motion tenderness. Which of the following is the most likely cause of this patient’s abortion?

A 30-year-old G3P2 woman at 25 weeks’ gestation has a history of gestational diabetes in her previous pregnancy. Her fasting blood glucose level at her initial 10-week screening visit was 110 mg/dL and urinalysis was negative for glucose in the urine. The patient has not been taking her own blood sugars at home, but she has been adhering to a low-carbohydrate diet. Over the past several weeks, she has noticed increased fatigue and polyuria. Which of the following is the next most appropriate step?

A 31-year-old woman with systemic lupus erythematosus who is 4 weeks pregnant presents to her obstetrician for her first prenatal visit. She is very concerned that the lupus will affect her baby. She was diagnosed with systemic lupus erythematosus 5 years ago and her symptoms have been well controlled with low-dose prednisone. She has baseline renal insufficiency, with a creatinine level of 1.3 mg/dL that has been stable for the past 6 months. This is her first pregnancy. For which of the following is the baby at increased risk?

A 30-year-old G0 woman with a past medical history of dysmenorrhea presents to an infertility clinic with her husband for a follow-up visit. The couple has been trying to get pregnant for the past 3 years with no success. Their infertility work-up thus far has included a semen analysis, hysterosalpingogram, and estrogen, progesterone, and follicle-stimulating hormone blood levels, all of which were normal. Currently the woman feels well; her only complaint is frustration regarding her inability to conceive. A pelvic ultrasound done last week demonstrated a 3-cm well-circumscribed mass on the patient’s left ovary. Her last menstrual period was 3 weeks ago. The ovarian mass most likely represents which of the following?

A 34-year-old G1P0 woman at 29 weeks’ gestation presents to the emergency department complaining of 2 hours of vaginal bleeding. The bleeding recently stopped, but she was diagnosed earlier with placenta previa by ultrasound. She denies any abdominal pain, cramping, or contractions associated with the bleeding. Her temperature is 36.8°C (98.2°F), blood pressure is 118/72 mm Hg, pulse is 75/min, and respiratory rate is 13/min. She reports she is Rh positive, her hemoglobin is 11.1 g/dL, and coagulation tests, fibrinogen, and D-dimer levels are all normal. On examination her gravid abdomen is non-tender. Fetal heart monitoring is reassuring, with a heart rate of 155/min, variable accelerations, and no decelerations. Two large-bore peripheral intravenous lines are inserted and two units of blood are typed and crossed. What is the most appropriate next step in management?

A 32-year-old G3P2 woman at 35 weeks’ gestation has a past medical history significant for hypertension. She was well-controlled on hydrochlorothiazide and lisinopril as an outpatient, but these drugs were discontinued when she found out that she was pregnant. Her blood pressure has been relatively well controlled in the 120–130 mm Hg systolic range without medication, and urinalysis has consistently been negative for proteinuria at each of her prenatal visits. She presents now to the obstetric clinic with a blood pressure of 142/84 mm Hg. A 24-hour urine specimen yields 0.35 g of proteinuria. Which of the following is the most appropriate next step?

A 32-year-old G2P1 woman at 35 weeks’ gestation presents to her obstetrician for a routine prenatal check-up. The mother has been previously diagnosed with mild preeclampsia, which the obstetrician has chosen to manage expectantly. During the visit, a biophysical profile is performed and the amniotic fluid index is found to be <5 cm, indicating the development of oligohydramnios. The biophysical profile is otherwise normal, with a total score of 8/10 and reassuring fetal heart tracings. How should oligohydramnios be managed in this patient?

At 38 weeks’ gestation, a 4030-g (8.9-lb) boy is delivered by spontaneous vaginal delivery. During the first minute of life he is limp, cyanotic, lacks respiratory effort, has a heart rate of 95/min, flexes his extremities, and grimaces to nasal suctioning. By 5 minutes, he continues to grimace to nasal suctioning, has a weak cry, is well perfused with a heart rate of 160/min, and is kicking both legs. Based on his Apgar scores, when will the child need to be resuscitated?

464. A 23-year-old G1P0 woman at 28 weeks’ gestation presents to her obstetrician for a prenatal examination. She has received poor prenatal care up to this point, but is confident about dating the pregnancy. She denies use of alcohol and illicit drugs but has continued to smoke during the pregnancy. The mother has gained only 9 kg (20 lb) during the course of the pregnancy. The mother’s temperature is 36.8°C (98.2°F), pulse is 94/min, blood pressure is 138/84 mm Hg, and respiratory rate is 12/min. The fundal height is 23 cm above the pubic symphysis. Further examination with ultrasound reveals the fetus is <10% of the expected weight for the gestational age with symmetric growth anomalies. What is the most likely cause for the intrauterine growth restriction of this fetus?

A 22-year-old obese woman presents to the obstetrics-gynecology clinic complaining of mild abdominal pain and vaginal bleeding. The patient states that she is sexually active with her boyfriend and uses condoms “basically all the time.” She states that her last menstrual period was 7 weeks ago and insists that her periods have always been irregular, occurring every 3 to 4 months. She denies any past medical history but states that she used to have a problem with excess facial hair prior to starting low-dose oral contraceptive pills. Which of the following is the best next step in diagnosis?

A full-term 2200-g (4.9-lb) boy was born to a 30-year-old G4P3 woman whose pregnancy was complicated by a seizure disorder for which she inconsistently took carbamazepine. The pregnancy was also notable for an abnormal triple screen for which an amniocentesis was declined. His Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. His temperature is 37.0°C (98.6°F), blood pressure is 65/45 mm Hg, heart rate is 110/min, and respiratory rate is 30/min. His head circumference is <5th percentile. There is a small fleshy sac protruding from the sacral spine. His reflexes are 2+ throughout, and his strength is 5/5 in all extremities. His fingernails are very small. Which of the following is the most likely diagnosis?

A 24-year-old G1P0 woman at 31 weeks’ gestation presents to the emergency department with a 4-hour history of abdominal cramping and contractions. The contractions have been regularly spaced at 10 minutes, but seem to be increasing in intensity. She has had a small amount of vaginal discharge, but is unable to definitively say whether her water has broken. She has not had any vaginal bleeding. Her temperature is 36.8°C (98.3°F), blood pressure is 137/84 mm Hg, pulse is 87/min, and respiratory rate is 12/min. Physical examination reveals a non-tender abdomen with palpable contractions every 8 minutes. Which of the following is the best next step in management?

20-year-old G1 at 36 weeks is being monitored for preeclampsia; she rings the bell for the nurse because she is developing a headache and feels funny. As you and the nurse enter the room, you witness the patient undergoing a tonic-clonic seizure. You secure the patient’s airway, and within a few minutes the seizure is over. The patient’s blood pressure monitor indicates a pressure of 160/110 mm Hg. Which of the following medications is recommended for the prevention of a recurrent eclamptic seizure?

You are doing postpartum rounds on a 22-year-old G1P1, who vaginally delivered an infant male at 36 weeks after an induction for severe preeclampsia. During her labor she required hydralazine to control her blood pressures. She is on magnesium sulfate for seizure prophylaxis. Her vital signs are: blood pressure 154/98 mm Hg, pulse 93 beats per minute, respiratory rate 24 breaths per minute, and temperature 37.3C. She has adequate urine output at greater than 40 cc/h. On examination, she is oriented to time and place, but she is somnolent and her speech is slurred. She has good movement and strength of her extremities, but her deep tendon reflexes are absent. Which of the following is the most likely cause of her symptoms?

A 28-year-old woman and her husband present to her obstetrician. They have been married for 7 years and have been trying to become pregnant for the past 2 years. Prior to this the woman used an intrauterine device for contraception, which she had in place for 5 years. Both are healthy without any medical problems, and both deny a history of sexually transmitted diseases. The woman states that her menstrual cycles have always been regular (every 28 days, lasting for 5 days) since she was 14 years old. She also denies menorrhagia and dysmenorrhea. Which of the following is the most likely cause of this couple’s infertility?

A woman brings her 15-year-old daughter to her pediatrician for concerns about hair growth. The child has always had a lot of body hair and has been shaving her legs since she was 12 years old. The mother reports that her daughter has recently been noticing more hair, especially along the upper lip and on the chest and abdomen. The child is clearly distressed about her appearance. Further questioning reveals that although the girl had her first menses at 11 years old, her menstrual cycles are irregular, and she sometimes skips cycles for months at a time. Physical examination reveals a young, heavy-set, olive-skinned teenager with moderate acne and dark hair growth along her upper lip, across her chest, and over her lower abdomen. She exercises regularly. Which of the following is the most appropriate treatment for this child’s hirsutism?

A 28-year-old teacher presents to the clinic complaining of 5 months of polyuria, polydipsia, and weight loss. Additionally, her menses, which have always been irregular, have stopped altogether. She is concerned because both her mother and maternal aunt suffer from noninsulin-dependent diabetes, and they told her they had similar symptoms before they were diagnosed. Upon questioning she reveals that she is in a committed relationship and has no desire to have children, so she uses barrier protection during intercourse. Physical examination reveals an obese woman with hirsutism currently in no acute distress. Testing for β-human chorionic gonadotropin level, random blood sugar level, cholesterol panel, and a luteinizing hormone/follicle-stimulating hormone ratio suggests the patient has polycystic ovarian syndrome (PCOS). Although no one in her family has had cancer, she is concerned that her symptoms are a harbinger of cancer or that she might be likely to suffer from cancer in the future. This diagnosis would most raise her risk for which kind of cancer?

A 26-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling of her hands and feet. Her previous prenatal check-up was normal. Blood pressure is 150/95 mmHg, and five minutes later following lateral rest her blood pressure is 140/95 mmHg. Physical examination shows 2+ pitting edema of the legs and a macular eruption on the cheekbones. Optic fundi show no abnormalities. Laboratory studies are as follows: Urinalysis: 4+ protein, RBC casts Urine protein: 8 g/24hr Uric acid: 5 mg/dl BUN: 28 mg/dl Serum creatinine: 2.1 mg/dl Serum electrolytes, liver function tests and coagulation studies are within normal limits. A serum antinuclear antibody (ANA) test is positive in high titers. Which of the following is the most likely diagnosis?

A 23-year-old woman complains of breast pain two days after delivering her first child. The delivery was complicated by mild postpartum bleeding. On exam, both breasts are tense, warm, and tender to touch. Her blood pressure is 130/70 mmHg, heart rate is 100/min, and temperature is 99.4° F (37.4° C). What is the most likely diagnosis?

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?

A 21-year-old woman at 36 weeks gestation is admitted for delivery. She has severe preeclampsia. Her blood pressure is 190/110 mmHg, pulse is 80/min and respirations are 16/min. Physical examination shows 3+ pitting edema of the legs and brisk deep tendon reflexes. Fundoscopic examination shows no abnormalities. Laboratory studies show elevated BUN, serum creatinine and serum transaminases. Urinalysis shows 4+ proteinuria. Intravenous hydralazine and magnesium sulfate was initiated on admission. After stabilization, intravenous oxytocin and artificial rupture of membranes (AROM) was administered for induction of labor. Two hours later, her blood pressure is 150/90 mmHg, pulse is 78/min and respirations are 9/min. Repeat examination shows hyporeflexia and a completely effaced cervix that is 5 cm dilated. Which of the following is the most appropriate next step in management?

An 18-year-old woman comes to the physician for her annual physical examination. Her past medical history is unremarkable and she takes no medications. Her last menstrual period was 2 weeks ago, and she has regular menses lasting 4-5 days every 28 days. The patient became sexually active at age 16 and has had 3 partners since then. She is currently in a monogamous relationship with her boyfriend of a year and uses condoms regularly. The patient has no vaginal discharge, urinary complaints, or weight changes. Vital signs and general physical examination are within normal limits. She inquires about cervical cancer screening and human papillomavirus vaccine, which she has not received. What is the most appropriate next step in management of this patient?

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 (98.7°F), 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?

A 28-year-old G1A1 woman presents to a gynecology clinic with a chief complaint of reduced menstrual flow for the past 6 months, especially last month. She denies any pain with menstruation or irregularity in her cycle. She says that she had an elective termination by dilation and curettage approximately 9 months ago. She is sexually active with one partner and always uses condoms. Review of her records indicates a past history of abnormal Papanicolaou (Pap) smears, but she has not been followed recently. She denies any history of irregular menses, and says that age of menarche was 13 years. She takes no medications. Physical examination reveals a normally developed 68-kg (150lb) woman who is 183 cm (6') tall. She is in no acute distress. A β-human chorionic gonadotropin test from her original visit 1 week ago is negative. Which of the following is the most likely diagnosis?

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?

A 42-year-old postmenopausal woman presents to the clinic complaining of vague abdominal pain, early satiety, and a 9-kg (20-lb) unintended weight loss. She has a history of normal Pap smears. On physical examination her abdomen is firm, with evidence of ascites and a firm, irregular, and fixed left adnexal mass palpated on vaginal examination. CT scan of the abdomen and pelvis confirms the presence of an ovarian mass that has features that are highly suspicious for cancer. What is the best means to correctly diagnose and stage this mass?

A 55-year-old woman is brought to the emergency department by fi re and rescue personnel because of intractable back and thigh pain for the past 3 hours. Upon presentation she says that the pain is 9 of 10 in severity and localized to her lower back. She lives with her sister, and she has no primary care physician. She denies any complaints aside from fatigue, which she attributes to her multiple jobs and caring for her sister’s children. She has a pulse of 110/min, blood pressure of 140/88 mm Hg, respiratory rate of 20/min, and temperature of 37.8°C (100.1°F). On physical examination she is exquisitely tender over the L2–3 area of the spine. She also has point tenderness over the anterior right thigh. Sensation is intact over the lower extremities bilaterally and she has 5/5 strength in the lower extremities bilaterally. Breast examination reveals a retracted nipple and dimpling of the right breast. What will likely represent the mainstay of treatment for this patient’s symptoms?

A 57-year-old G3P3 woman presents to her gynecologist with complaints of vaginal pruritus and increased vaginal discharge. The patient has no history of gynecologic surgery or sexually transmitted diseases; she is not currently sexually active. A bimanual examination and Pap smear are performed. The Pap smear is positive for malignant squamous cells. Follow up colposcopy shows no cervical lesions, but a small lesion is noted on the lower vagina. Biopsy of this lesion confirms the diagnosis of vaginal squamous cell cancer, while cross-sectional imaging excludes invasion of surrounding tissues. What is the most appropriate course of treatment?

484. A 33-year-old G1P1 woman presents to her gynecologist for a Pap smear. It has been several years since she last saw a physician. She is not currently sexually active, but takes oral contraceptives. Her vaginal examination is normal, but her Pap smear shows moderate-grade cervical intraepithelial neoplasia. The patient undergoes colposcopy and biopsies, which confirm the diagnosis. What is the most appropriate management of this patient?

A 48-year-old woman presents to her gynecologist because of vaginal bleeding. She states that after a year of hot flashes and irregular cycles, she finally stopped menstruating 4 months ago. Two days ago she began having some vaginal bleeding that was very similar to her prior menses. She is concerned because she heard that the first sign of endometrial cancer in postmenopausal women is vaginal bleeding. She is an otherwise healthy woman with no medical problems. She exercises three times a week and takes multivitamins. She had three children when she was 29–35 years old. She used oral contraceptive pills for contraception from the time she was 18 until she got married at the age of 28. Which of the following is the most appropriate next step in managing this woman’s vaginal bleeding?

A 35-year-old G4P4 obese woman is referred to her gynecology clinic by her primary care physician for heavy menstruation and irregular cycles. She has noticed these symptoms for several months. She reports being a “late bloomer,” with onset of menses at age 13 years. She is sexually active and monogamous with her partner of 2 years. She is taking oral contraceptive pills and has a 5-year smoking history. An endometrial biopsy is read as “endometrial hyperplasia, cannot rule out intraepithelial carcinoma.” Β -Human chorionic gonadotropin testing is negative. Which of the following most likely contributed to this abnormality?

An 18-year-old woman presents to the clinic because of 6 hours of severe abdominal pain, nausea, and vomiting. She describes 6 days of mild lower abdominal pain, low-grade fever, and abnormal vaginal discharge. She is sexually active with two male partners, and her last menstrual period was 10 days ago. Her temperature is 39.5°C (103.2°F), blood pressure is 100/60 mm Hg, heart rate is 110/min, and respiratory rate is 18/min. Physical examination reveals involuntary abdominal guarding. The patient will not allow a pelvic examination. Which of the following is the most appropriate management?

A 65-year-old G2P2 postmenopausal woman presents to a gynecologist for the first time in many years complaining of vaginal bleeding, pelvic pain, and increased urinary frequency. She reports she is sexually active with her husband. After an appropriate work-up, a diagnosis of locally invasive squamous cell carcinoma of the cervix is made. The tumor has extended approximately 9 mm into the cervical stroma, grading the cancer as stage IB. The patient is informed of the diagnosis and wishes to undergo definitive therapy. What is the definitive therapy for this patient’s disease?

A 29-year-old African-American woman comes to the physician after discovering a mass on breast self-examination. Her last menstrual period was 2 weeks ago. She reports occasional bilateral gray nipple discharge that has not changed since menarche. She has no significant past medical history and does not take any medications. Examination reveals a 1.5-cm fluctuant mass in the upper and outer quadrant of the left breast. Which of the following is the best next step in management?

A 26-year-old G0 woman is seen in her gynecologist’s office for a routine examination. She reports that she has been sexually active with four partners and has been treated for gonorrhea once in the past year. She has otherwise been healthy. Physical examination is unremarkable. Results of a Pap smear suggest a low-grade squamous intraepithelial lesion. What is the most appropriate next step in management?

During routine breast examination of a 28-yearold 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?

A 52-year-old postmenopausal woman who was diagnosed with advanced ovarian cancer presents to the clinic to discuss her treatment options. She has had a CT of the abdominalpelvic region that showed extensive disease extending from her left ovary and involving her uterus along with large pelvic nodes. What is the best treatment for this patient?

An 18-year-old female college student presents to student health services with a complaint of a burning sensation while urinating and abdominal pain. She denies urinary urgency or increased frequency. She has no significant past medical history. She is currently sexually active with a new partner. She does not use barrier contraception. She denies any previous history of sexually transmitted diseases. On examination she is afebrile, heart rate is 70/min, and blood pressure is 120/60 mm Hg. Examination reveals no peritoneal signs but there is tenderness to palpation over the suprapubic region. On pelvic examination the cervix appears edematous and friable with a small amount of discharge from the os. A urine sample reveals numerous WBCs but no organisms on Gram stain. A cervical swab is sent for Gram stain and culture. Which of the following is the most likely explanation for these findings?

494. A 13-year-old girl had growth of breast buds at 11 years, followed by the appearance of pubic hair between the ages of 11 1/2 and 12 years. Which pubertal event is most likely to occur next?

A 17-year-old G1P1001 is now 5 weeks postpartum after a routine vaginal delivery. She calls your office to report a 3-week history of difficulty sleeping and “feeling blue.” On further questioning, she reports difficulty concentrating, very poor appetite, occasional wishes that she had never become pregnant, and feelings of guilt about those wishes. She has not left her home in more than a week because she “just can’t find the energy to go anywhere.” This patient’s symptoms are most consistent with:

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?

A 31-year-old pregnant woman 6–7 weeks from her last menses comes to the emergency department of your hospital complaining of lower abdominal pain for 3 hours. The pain is diffused in the lower abdomen but worse on the right side. Her serum human chorionic gonadotropin (hCG) concentration is 9600 mIU/mL. Which of the following is the strongest evidence that she has a tubal ectopic pregnancy?

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?

48-year-old woman with five children complains of urinary incontinence with coughing and stair climbing. She likely has genuine stress urinary incontinence if which of the following is true?

A 22-year-old primiparous woman is in premature labor at 30 weeks’ gestation. Despite administration of tocolytic agents, it seems she will deliver soon. Pulmonary maturity might be enhanced by the administration of which of the following drugs?

An 18-year-old nullipara has suddenly stopped menstruating. She recently lost 8.6 kg when she started long-distance running. The laboratory test most consistent with her cause of secondary amenorrhea is which of the following?

A 22-year-old woman with cystic fibrosis is engaged to be married and asks you about childbearing. How should you advise her?

On the first pelvic examination of an 18-yearold nulligravida, a soft, fluctuant mass is found in the superior aspect of the right labia majora. This is asymptomatic. She tells you it has been present for several years and seems to be enlarging slightly. There is no defect in the inguinal ring. Which of the following is the most likely diagnosis?

Your patient has just had twins and wonders if there is any way to determine whether the twins are identical. You correctly tell her which of the following?

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

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?

A 34-year-old woman, gravida 3, para 2, at 16 weeks' gestation comes to the physician concerned that she may have been exposed to an infectious disease. Yesterday, she and her 5-year-old son spent a day at the beach with one of his classmates. This morning, the classmate was sent home from school with a fever and rash that the teacher thought, were suspicious for chickenpox. The patient is unsure whether she had chickenpox as a child. Her temperature is 37 0C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 88/min, and respirations are 16/min. Her examination is unremarkable. An inquiry made by the physician confirms that the classmate has chickenpox. Which of the following is the most appropriate next step in management?

A 26-year-old primigravid woman at 10-weeks' gestation comes to the physician for a routine prenatal appointment Her dating is based on a 6-week ultrasound. She has sickle-cell anemia. She has no past surgical history, takes prenatal vitamins, and has no known drug allergies. She tells the physician that she recently learned that the father of the baby has sickle-cell trait. On examination, her uterus is appropriate for a 10-week gestation, and fetal heart tones are heard. Her hematocrit is 37%. What is the most appropriate next step in the management of this patient?

A 23-year-old woman, gravida 1, para 0, at 25 weeks’ gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows: Leukocyte count 10,500/mm3 Platelet count 62,000/mm3 Hematocrit Sodium Chloride Potassium Bicarbonate 26% 140 mEq/L 100 mEq/L 4.5 mEq/L 26 mEq/L A peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?

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?

A 22-year-old woman comes to the physician seeking advice. Last night, while she was having sexual intercourse, the condom broke. She is very concerned that she may become pregnant and wants to know whether she can do anything at this point. She has no medical problems and has never had surgery. She takes ibuprofen for dysmenorrhea. She is allergic to sulfa drugs. On physical examination, she is anxious and intermittently sobbing. Her temperature is 37 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 98/min, and respirations are 24/min. The remainder of her physical examination is unremarkable. A urine pregnancy test is negative. Which of the following is the most appropriate pharmacotherapy?

A 42-year-old woman comes to the physician because of vaginal itch and discharge, dysuria, and dyspareunia. These symptoms have been steadily worsening over the past 3 days. Pelvic examination reveals an erythematous vagina and a thin, green, frothy vaginal discharge with a pH of 6. Microscopic examination of the discharge demonstrates the presence of a pear-shaped, motile organism. Which of the following is the most likely pathogen?

A 34-year-old woman, gravida 4, para 3 at 38 weeks' gestation, comes to the labor and delivery ward because of contractions. Her prenatal course was significant for low maternal weight gain. She had a normal 18-week ultrasound survey of the fetus and normal 36-week ultrasound to check fetal presentation. Her blood type is O positive, and she is rubella immune. Three years ago, she had a multiple myomectomy. She takes prenatal vitamins and has no known drug allergies. She smokes one pack of cigarettes per day. Which of the following complications is most likely to occur?

A 39-year-old woman, gravida 3, para 2 at 34 weeks' gestation, with a known history of chronic hypertension, is found to have a blood pressure of 180/115 mm Hg at a routine prenatal visit. Her prenatal course had been otherwise unremarkable. She is transferred to the labor and delivery ward for further management. IV antihypertensive medications should be given to this patient with a goal of which of the following blood pressures?

A 33-year-old woman comes to the physician because she has not had a menstrual period for 6 months. Prior to this she had a normal period every 29 days that lasted for 4 days. She has noted some weight gain in the past few months. She has a history of hepatitis A infection 6 years ago and had an appendectomy at age 12. She takes no medications and has no allergies to medications. Her father died of acute pancreatitis 3 years ago. Her mother is alive and well with no medical problems. Which of the following is the most appropriate next step in diagnosis?

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?