Gyneco_USMLE 633-732

633. A 30-year-old G3P3 is being evaluated for urinary urgency, urinary frequency, and dysuria. She also complains of pain with insertion when attempting intercourse. She frequently dribbles a few drops of urine after she finishes voiding. She has had three full-term spontaneous vaginal deliveries. Her last baby weighed more than 9 lb. She had multiple sutures placed in the vaginal area after delivery of that child. She also has a history of multiple urinary tract infections since she was a teenager. On pelvic examination, she has a 1-cm tender suburethral mass. With palpation of the mass, a small amount of blood-tinged pus is expressed from the urethra. Which of the following is the most likely cause of this patient’s problem?

634. A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?

635. A 27-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with a gush of fluid and regular contractions. Examination shows that she is grossly ruptured, contracting every 2 minutes, and that her cervix is dilated to 4 cm. The fetal heart rate tracing is in the 140s and reactive. She is admitted to labor and delivery, and over the following 4 hours she progresses to 9 cm dilation. Over the past hour, the fetal heart rate has increased from a baseline of 140 to a baseline of 160. Furthermore, moderate to severe variable decelerations are seen with each contraction. The fetal heart rate does not respond to scalp stimulation. The decision is made to proceed with cesarean delivery. Which of the following is the reason for the cesarean delivery and the preoperative diagnosis?

636. A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony-forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery?

637. 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?

638. A 22-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward with a gush of fluid. Sterile speculum examination reveals a pool of fluid that is nitrazine positive and forms ferns when viewed under the microscope. The fetal heart rate is in the 150s and reactive. An ultrasound demonstrates that the fetus is in the breech position. A cesarean delivery is performed. During the operation, the physician, who has received no recent immunizations, is stuck with a needle that had been used on the patient. Which of the following is this physician at greatest risk of contracting?

639. A 43-year-old African American woman comes to the physician because of her concern regarding breast cancer. She has no complaints at present. In past years, she had noted bilateral breast tenderness prior to her menses, but this has since abated. She has no medical problems. She had two cesarean deliveries, but no other surgeries. She takes a low-dose oral contraceptive pill and has no known drug allergies. She does not smoke, and her family history is negative. Physical examination is normal. All mammograms (yearly since age 40) have been negative to date. She wants to know whether BRCA1 and BRCA2 screening would be appropriate for her. Which of the following is the correct response?

640. A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing. Two years ago she chose to have an elective repeat cesarean delivery rather than attempt a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except that she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve prolapse, but no other structural cardiac disease. Which of the following is the correct management of this patient?

641. A 38-year-old woman, gravida 4, para 4, comes to the physician 8 days after a cesarean delivery complaining of redness and pain at the leftmost aspect of her incision. Her cesarean delivery was performed secondary to a non-reassuring fetal heart rate tracing. She was feeling well after the operation until 4 days ago, when she developed pain and redness around her incision. Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 88/min, and respirations are 12/min. There is marked erythema and induration around the incision. At the left margin of the incision there is a fluctuant mass. Which of the following is most appropriate next step in management?

642. A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a gush of fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions present, oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having contractions every minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal heart rate changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the cervix is 6 cm dilated. Which of the following is the most appropriate next step in management?

643. A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?

644. A 22-year-old primigravid woman at term comes to the labor and delivery ward because of painful contractions every 2 minutes. She has had no gush of fluid and no bleeding from the vagina. Her prenatal course was unremarkable. She takes no medications and has no allergies to medications. Examination shows that her cervix is 6 cm dilated and 100% effaced; the fetus is at 0 station. The fetal heart rate has a baseline in the 150s and is reactive. The patient desires an epidural for pain relief. Which of the following should be given orally shortly before the epidural is placed?

645. A 39-year-old woman, gravida 4, para 3, comes to the physician for a prenatal visit. Her last menstrual period was 8 weeks ago. She has had no abdominal pain or vaginal bleeding. She has no medical problems. Examination is unremarkable except for an 8-week sized, nontender uterus. Prenatal labs are sent. The rapid plasma reagin (RPR) test comes back as positive and a confirmatory microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP) test also comes back as positive. Which of the following is the most appropriate pharmacotherapy?

646. A 67-year-old woman comes to the physician because of pain with urination and frequent urination. She has hypertension for which she takes a beta-blocker, but no other medical problems. She states that she is not sexually active. She does not smoke and drinks cranberry juice daily. Examination shows mild suprapubic tenderness and genital atrophy but is otherwise unremarkable. Urinalysis shows 50 to 100 leukocytes/high powered field (hpf) and 5 to 10 erythrocytes/hpf. Which of the following is the most likely cause of the infection?

647. A 39-year-old woman, gravida 2, para 1, at 30-weeks gestation comes to the physician for a prenatal visit. The patient's due date was determined by a 7-week ultrasound. Her prenatal course has been unremarkable. She has no complaints of contractions, loss of fluid, or bleeding from the vagina, and her baby is moving well. Examination demonstrates a fetal heart rate of 150 and a fundal height of 27 centimeters, which is the same measurement as that determined 4 weeks ago. This patient's fundal height measurement is most suggestive of which of the following?

648. A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?

649. A 40-year-old woman comes to the physician for an annual examination. She has no complaints. She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She has no known drug allergies. Examination is unremarkable, including a normal pelvic examination. One of her friends was recently diagnosed with endometrial cancer, and the patient wants to know when and if she needs to be screened for this. Which of the following is the most appropriate response?

650. A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient?

651. A 21-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician because of a malodorous vaginal discharge. She states that she first noticed the discharge 2 days ago and since then it has become more profuse and malodorous. Her prenatal course has been unremarkable during this pregnancy. Her prior pregnancy was complicated by preterm labor and delivery at 31 weeks' gestation. Examination shows a grayish vaginal discharge. A strong amine odor is released when KOH is applied to a sample of the discharge. Examination of a normal saline ("wet") preparation reveals numerous "clue" cells. Which of the following is the most appropriate pharmacotherapy?

652. A 23-year-old woman comes to the physician because she thinks that she may be pregnant. She missed her last two periods and feels "different." A urine pregnancy test is positive and an ultrasound reveals a 12-week fetus. The patient is very concerned because she received the measles-mumps-rubella (MMR) vaccine four months ago and was told to wait 3 months before attempting conception. The pregnancy is desired. The patient asks if she should have a termination of pregnancy because she was vaccinated shortly before becoming pregnant. Which of the following is the most appropriate response?

653. A 22-year-old woman comes to the physician because of a missed menstrual period. She has a complex past medical history. She has hypothyroidism, for which she takes thyroxine, she has an artificial heart valve, for which she takes Coumadin, and she recently started tetracycline for acne. She does not think that she is pregnant because she is currently on the oral contraceptive pill, but, if pregnant, she would keep the pregnancy. Physical examination, including pelvic examination, is unremarkable. Urine human chorionic gonadotropin (hCG) is positive. Which of the following medications should the patient continue to take during the pregnancy?

654. A 19-year-old nulligravid woman comes to the emergency department because of severe left lower quadrant pain. She has been noticing this pain intermittently for the past 3 days, but this afternoon it became persistent and severe and was accompanied by nausea and vomiting. Examination shows left lower quadrant tenderness and a tender left adnexal mass. Urine hCG is negative. Pelvic ultrasound shows a 7 cm left ovarian complex mass. Which of the following is the most appropriate next step in management?

655. A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and swelling in her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal thrombus in the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an advantage of low-molecular-weight heparin compared with unfractionated heparin?

656. A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy with no significant past medical history. Examination is significant for a temperature of 38.3 C (101 F), moderate costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine. The patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two days, she rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty, feeling no pain, and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in management?

657. 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?

658. A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?

659. A 19-year-old female comes to the physician because she has not had a menstrual period. She experienced normal breast development through puberty but has yet to have a period. She has no other complaints. She has no medical problems. Examination shows the patient to be tall with long arms and big hands. The breasts are normal-appearing except that the nipples are immature and the areolae are pale. Pelvic examination shows scant pubic hair with a blind-ended vaginal pouch. Which of the following is the most likely diagnosis?

660. A 53-year-old woman comes to the physician because of concerns regarding menopause. She has a period almost every month, but her cycle is lengthening. She is worried because her mother, her two older sisters, and practically all her aunts have osteoporosis. She does not want to be on estrogen because she is concerned about cancer and thrombosis. Physical examination is within normal limits. The patient is started on raloxifene. On this medication, which of the following is this patient most likely to develop?

661. A 47-year-old woman comes to the physician for an annual examination. One year ago, she was diagnosed with endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. She was found to have grade I, stage I, disease at that time. Over the past year, she has developed severe hot flashes that occur throughout the day and night and are worsening. She is also concerned because her mother and several of her aunts have severe osteoporosis. She wonders whether she can take estrogen replacement therapy. Which of the following is the most appropriate response?

662. A 32-year-old woman, gravida 3, para 0, at 29 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. She had a prophylactic cerclage placed at 12 weeks' gestation because of her history of two consecutive 20-week losses. These spontaneous abortions were both characterized by painless cervical dilation, with the membranes found bulging into the vagina on examination. Ultrasound now demonstrates her cervix to be long and closed with no evidence of funneling. Which of the following is the most appropriate time to remove the cerclage from this patient?

663. A 55-year-old woman comes to the physician because of hot flashes. She first noted them about 9 months ago, and since then they have been worsening. She states that the flashes come on at various times throughout the day, but that they are especially intense at night. She had her last menstrual period approximately 5 months ago. Her medical history is significant for a pulmonary embolus at the age of 36 and severe depression. She takes fluoxetine for depression and has no allergies to medications but smokes one pack of cigarettes per day. Physical examination is unremarkable, including a normal pelvic examination. Which of the following is the most appropriate pharmacotherapy for this patient?

664. A 24-year-old woman comes to the physician for an initial prenatal visit. Her last menstrual period was 7 weeks ago and a home urine pregnancy test was positive. She has had no bleeding or abdominal pain. She does complain of increased fatigue lately and some mild nausea and vomiting. Examination is significant for both a systolic and a diastolic cardiac murmur. The uterus is 8 weeks' sized and nontender. Which of the following findings is most suggestive of structural heart disease in this woman?

665. 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?

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?

667. 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?

668. 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?

669. 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?

670. A 75-year-old woman comes to the physician because of abdominal distension. She states that she always feels bloated and that she gets full quickly when eating. She has hypertension, for which she takes an angiotensin converting enzyme (ACE) inhibitor, and no other medical problems. Examination shows abdominal distension and a positive fluid wave. Pelvic examination reveals a large, nontender right adnexal mass. Abdominal CT scan demonstrates masses on both ovaries, ascites, and omental caking. CA-125 level is significantly elevated. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are negative. Which of the following is the most likely diagnosis?

671. 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?

672. 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?

673. A 25-year-old woman who is “about 5 months” pregnant with her first child presents for the first time to an obstetrician. She has had no prenatal care. When asked about her medical history, she states she sometimes takes medicine for “depression,” and she produces a prescription bottle with lithium tablets in it. She is otherwise healthy and her pregnancy has been uncomplicated to date. The fundus of her uterus is 22 cm from the pubic symphysis, fetal movement is felt, and fetal heart tones are present at 130/min. Which of the following tests should be advised given the patient’s lithium ingestion?

674. 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?

675. A 20-year-old woman presents to her gynecologist complaining of several days of vaginal itching and increased vaginal secretions that have an unpleasant odor. She denies any recent fever, back pain, hematuria, or vaginal bleeding. She has been sexually active with multiple sexual partners and rarely uses protection. On examination she has a moderate amount of frothy green discharge. Amine “whiff” test of the discharge is negative, and the pH of the discharge is 6. Multiflagellated organisms are seen on microscopy. Which of the following is the most likely diagnosis?

676. A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2° C (98.9° F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 % Platelets: 200,000/mm3 Serum sodium: 130 mEq/L Serum potassium: 2.8 mEq/L Chloride: 86 mEq/L Bicarbonate: 30 mEq/L Blood urea nitrogen (BUN): 30 mg/dl Serum creatinine: 1.6 mg/dl Blood glucose: 98 mg/dl Which of the following is the most appropriate next step in management?

677. A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a motor vehicle accident. She had intense abdominal pain and became agitated and restless in the ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood pressure is 90/60mmHg, pulse is 120/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. Fetal heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/min. Which of the following is the most likely diagnosis?

678. 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?

679. A 20-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling in her hands and ankles. She has no headache, visual disturbances or epigastric pain. She has no previous medical problems. She does not use tobacco, alcohol or illicit drugs. Her previous prenatal check-up at 28 weeks gestation was normal. Her medical records show no preexisting hypertension or proteinuria. Her blood pressure is 156/100 mmHg, and after 15 minutes of lateral rest, a repeat reading is 154/98 mmHg. Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal. Fundoscopic examination shows no abnormalities. Fetal heart tones are audible by Doppler. Laboratory studies show: Hb: 13.0 g/dl Hct: 50% Platelets: 300,000/mm3 Creatinine: 1.1 mg/dl 24hour urine protein excretion is 1gm, which is new. Which of the following is the most likely diagnosis?

680. 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?

681. A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?

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

683. 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?

684. 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?

685. 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?

686. 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?

687. 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?

688. A 29-year-old G3P2 black woman in the thirty-third week of gestation is admitted to the emergency room because of acute abdominal pain that has been increasing during the past 24 hours. The pain is severe and is radiating from the epigastrium to the back. The patient has vomited a few times and has not eaten or had a bowel movement since the pain started. On examination, you observe an acutely ill patient lying on the bed with her knees drawn up. Her blood pressure is 100/70 mm Hg, her pulse is 110 beats per minute, and her temperature is 38.8C (101.8F). On palpation, the abdomen is somewhat distended and tender, mainly in the epigastric area, and the uterine fundus reaches 31 cm above the symphysis. Hypotonic bowel sounds are noted. Fetal monitoring reveals a normal pattern of fetal heart rate (FHR) without uterine contractions. On ultrasonography, the fetus is in vertex presentation and appropriate in size for gestational age; fetal breathing and trunk movements are noted, and the volume of amniotic fluid is normal. The placenta is located on the anterior uterine wall and no previa is seen. Laboratory values show mild leukocytosis (12,000 cells per mL); a hematocrit of 43; mildly elevated serum glutamicoxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and bilirubin; and serum amylase of 180 U/dL. Urinalysis is normal. Which of the following is the most likely diagnosis?

689. 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?

690. 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?

691. 27-year-old healthy woman comes to the office for evaluation of infertility. She and her 31 -year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. Her husband is healthy and takes no medications. He has a normal semen analysis. She has regular 28-day menstrual cycles. The patient has mid-cycle pelvic pain and an egg white like consistency to her discharge mid-cycle. She has no pain during sexual intercourse. The patient does report having been hospitalized with a pelvic infection in her late teens, during which time she had pain with intercourse, discharge, and fever. Her sister was diagnosed with polycystic ovarian disease. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is most likely to be abnormal in this patient?

692. A 29-year-old woman, gravida 3, para 2, at 35 weeks gestation is brought to the emergency department because of vaginal bleeding. She has had no uterine contractions. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Four years ago, she had a low transverse cesarean section in her second pregnancy. Physical examination shows bright red vaginal bleeding. Her temperature is 37.0° C (98.7° F), blood pressure is 100/70 mm Hg, pulse is 90/min and respirations are 16/min. Fetal heart monitoring is reassuring. Which of the following is the most likely diagnosis?

693. 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 (99.0°F), blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min. Physical examination is unremarkable. Her BUN is 18 mg/dl and creatinine is 1.4 mg/dl. A repeat β-HCG test performed in the office confirms pregnancy. Which of the following is the most appropriate next step in management?

694. A 30-year-old obese woman comes to the physician with a six-month history of oligomenorrhea. She has never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 21; none of which have shown any abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is indicated in the initial workup of this patient?

695. 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?

696. 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?

697. A 38-year-old G1P0 presents to the obstetrician’s office at 37 weeks gestational age complaining of a rash on her abdomen that is becoming increasingly pruritic. The rash started on her abdomen, and the patient notes that it is starting to spread downward to her thighs. The patient reports no previous history of any skin disorders or problems. She denies any malaise or fever. On physical examination, she is afebrile and her physician notes that her abdomen, and most notably her stretch marks, is covered with red papules and plaques. No excoriations or bullae are present. The patient’s face, arms, and legs are unaffected by the rash. Which of the following is this patient’s most likely diagnosis?

698. 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?

699. 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?

700. A 28-year-old G1 presents to your office at 8 weeks gestation. She has a history of diabetes since the age of 14. She uses insulin and denies any complications related to her diabetes. Which of the following is the most common birth defect associated with diabetes?

701. A 32-year-old G1 at 10 weeks gestation presents for her routine OB visit. She is worried about her pregnancy because she has a history of insulin-requiring diabetes since the age of 18. Prior to becoming pregnant, her endocrinologist diagnosed her with microalbuminuria. She has had photo laser ablation of retinopathy in the past. Which diabetic complication is most likely to be worsened by pregnancy?

702. 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?

703. A 40-year-old G3P2 obese patient at 37 weeks presents for her routine OB visit. She has gestational diabetes that is controlled with diet. She reports that her fasting and postprandial sugars have all been within the normal range. Her fetus has an estimated fetal weight of 6.5 lb by Leopold maneuvers. Which of the following is the best next step in her management?

704. A 36-year-old G1P0 at 35 weeks gestation presents to labor and delivery complaining of a several-day history of generalized malaise, anorexia, nausea, and emesis. She denies any headache or visual changes. Her fetal movement has been good, and she denies any regular uterine contractions, vaginal bleeding, or rupture of membranes. On physical examination, you notice that she is mildly jaundiced and appears to be a little confused. Her vital signs indicate a temperature of 37.7C (99.9F), pulse of 70 beats per minute, and blood pressure of 100/62 mm Hg. Blood is drawn and the following results are obtained: WBC = 25,000, Hct = 42.0, platelets = 51,000, SGOT/PT= 287/350, glucose = 43, creatinine = 2.0, fibrinogen = 135, PT/PTT = 16/50 s, serum ammonia level = 90 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones. Which of the following is the most likely diagnosis?

705. A 27-year-old G1P0 at 34 weeks gestation presents to your office complaining of a 2-day history of nausea and emesis. On physical examination, you notice that she is icteric sclera and skin. Her vital signs indicate a temperature of 37.2C (99F), pulse of 102 beats per minute, and blood pressure of 130/84 mm Hg. She is sent to labor and delivery for additional evaluation. In labor and delivery, the fetal heart rate is in the 160s with good variability, but nonreactive. Blood is drawn and the following results are obtained: WBC = 22,000, Hct = 40.0, platelets = 72,000, SGOT/PT = 334/386, glucose = 58, creatinine = 2.2, fibrinogen = 209, PT/PTT = 16/50 s, serum ammonia level = 65 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones. Which of the following is the recommended treatment for this patient?

706. A 32-year-old G1P0 reports to your office for a routine OB visit at 14 weeks gestational age. Labs drawn at her first prenatal visit 4 weeks ago reveal a platelet count of 60,000, a normal PT, PTT and bleeding time. 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 reveals the presence of trace protein. The patient denies any complaints. The only medication she is currently taking is a prenatal vitamin. On taking a more in-depth history you learn that, prior to pregnancy, your patient had a history of occasional nose and gum bleeds, but no serious bleeding episodes. She has considered herself to be a person who just bruises easily. Which of the following is the most likely diagnosis?

707. 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?

708. 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?

709. One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?

710. A 20-year-old G1 patient delivers a live-born infant with cutaneous lesions, limb defects, cerebral cortical atrophy, and chorioretinitis. Her pregnancy was complicated by pneumonia at 18 weeks. What is the most likely causative agent?

711. A 34-year-old G2 at 36 weeks delivers a growth-restricted infant with cataracts, anemia, patent ductus arteriosus, and sensorineural deafness. She has a history of chronic hypertension, which was well controlled with methyldopa during pregnancy. She had a viral syndrome with rash in early pregnancy. What is the most likely causative agent?

712. A 25-year-old G3 at 39 weeks delivers a small-for-gestational-age infant with chorioretinitis, intracranial calcifications, jaundice, hepatosplenomegaly, and anemia. The infant displays poor feeding and tone in the nursery. The patient denies eating any raw or undercooked meat and does not have any cats living at home with her. She works as a nurse in the pediatric intensive care unit at the local hospital. What is the most likely causative agent?

713. A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her early third trimester delivers a growth-restricted infant with seizures, intracranial calcifications, hepatosplenomegaly, jaundice, and anemia. What is the most likely causative agent?

714. A 32-year-old G5 delivers a stillborn fetus at 34 weeks. The placenta is noted to be much larger than normal. The fetus appeared hydropic and had petechiae over much of the skin. What is the most likely causative agent?

715. A 38-year-woman at 39 weeks delivers a 7-lb infant female without complications. At 2 weeks of life, the infant develops fulminant liver failure and dies. What is the most likely causative virus?

716. A 20-year-old woman who works as a kindergarten teacher presents for her routine visit at 32 weeks. Her fundal height measures 40 cm. An ultrasound reveals polyhydramnios, an appropriately grown fetus with ascites and scalp edema. The patient denies any recent illnesses, but some of the children at her school have been sick recently. What is the most likely cause of the fetal findings?

717. A 25-year-old female in her first pregnancy delivers a 6-lb male infant at 38 weeks. The infant develops fever, vesicular rash, poor feeding, and listlessness at 1 week of age. What is the most likely cause of the infant’s signs and symptoms?

718. A 22-year-old woman delivers a 7-lb male infant at 40 weeks without any complications. On day 3 of life, the infant develops respiratory distress, hypotension, tachycardia, listlessness, and oliguria. What is the most likely cause of the infant’s illness?

719. 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?

720. 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?

721. 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 45o 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?

722. 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?

723. A 38-year-old G6P4 is brought to the hospital by ambulance for vaginal bleeding at 34 weeks. She undergoes an emergency cesarean delivery for fetal bradycardia under general anesthesia. In the recovery room 4 hours after her surgery, the patient develops respiratory distress and tachycardia. Lung examination reveals rhonchi and rales in the right lower lobe. Oxygen therapy is initiated and chest x-ray is ordered. Which of the following is most likely to have contributed to her condition?

724. 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?

725. A 32-year-old G3P2 at 39 weeks gestation presented to the hospital with ruptured membranes and 4 cm dilated. She has a history of two prior vaginal deliveries, with her largest child weighing 3800 g at birth. Over the next 2 hours she progresses to 7 cm dilated. Two hours later, she remains 7 cm dilated. The estimated fetal weight by ultrasound is 3200 g. Which of the following labor abnormalities best describes this patient?

726. 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?

727. 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?

728. 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?

729. 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?

730. 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?

731. 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?

732. 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?