Show:
FEVER
Prenatal Care
Drugs/Infection
Postpartum
Labor and Delivery
100
An 18-year-old woman, gravida 1, para 0, at 41 weeks of gestation has had rupture of membranes for approximately 17 hours. She is in early labor with contractions every 5 minutes with cervical dilation at 5–6 cm. She received an epidural for pain relief 12 hours ago. Her temperature is 38.5° C (101°F). Her pulse is 124 beats per minute (bpm) and the fetal heart rate is 175 bpm with accelerations. She does not have any shortness of breath, dyspnea, or headaches. Her physical examination is notable for fundal tenderness. On admission, her white blood cell count was 18,000 cells/mm3 and her urinalysis had negative leukocyte esterase and nitrites. The most likely cause of her fever is
What is chorioamnionitis (1)
100
A 28-year-old woman, gravida 2, para 1, comes to the office for a routine prenatal visit at 38 weeks of gestation. She started her pregnancy at a normal weight for her height and has gained 8.2 kg (18 lb) to date. Her first child was delivered vaginally at 39 weeks of gestation and weighed 3,750 g. Her 1-hour glucose tolerance test is normal. Her blood pressure is 110/70 mm Hg with a normal urinalysis. On physical examination, the fundal height is 39 cm and Leopold maneuvers suggest an infant in cephalic presentation that weights approximately 3,860 g (8.5 lb). The fetal heart rate is 130 beats per minute. Her cervix is closed, long, and firm. Ultrasonography shows a singleton pregnancy in cephalic presentation with an estimated fetal weight of 4,110g (9 lb). The best next step in management is
what is expectant management (3)
100
A 30-year-old primigravid woman comes to your office for her first prenatal visit at 12 weeks of gestation. She has mild hypertension that has been treated with pharmacotherapy for the past year. She reports first-trimester exposure to an angiotensin converting enzyme (ACE) inhibitor. Her renal function is normal and she had a negative screen result for diabetes mellitus in the past year. The most appropriate next step to identify fetal abnormalities associated with ACE inhibitor therapy is
What is target ultrasound (9)
100
A patient is seen 16 hours after she underwent a spontaneous vaginal delivery of a 4,138 g (9 lb 2 oz) infant and is noted to have a 6 × 5 cm right vulvar hematoma. She is uncomfortable and voiding is difficult. She is observed for 2 hours and the hematoma does not seem to be expanding. Her hematocrit is 30%, having decreased from a predelivery value of 36%, and her vital signs are stable. Rectovaginal examination reveals no hematoma. The best next step in management is
What is observation (12)
100
A 19-year-old woman, gravida 1, is in spontaneous labor at 41 weeks of gestation. Initially, her cervix was 2 cm, 90% effaced, and the fetus was at –1 station. Clinical examination reveals an adequate maternal pelvis and an estimated fetal weight of 3,700 g. She receives oxytocin for labor augmentation. Her cervical examination progressed to 4 cm, 100% effacement, and 0 station, but has not changed for 2 hours and 20 minutes. The fetal heart rate tracing is Category I. An intrauterine pressure catheter is in place and she is contracting adequately on 20 mU/min of oxytocin. The best next step in management is
What is continue labor (10)
200
A 26-year-old multiparous woman presents with cough and fever. She resides in a shelter and has had no prenatal care. She has received no recent antibiotics and reports no chronic illness. Bedside ultrasonography suggests she is at 22 weeks of gestation. Her temperature is 38.9°C (102°F), respiratory rate is 26 breaths per minute, maternal heart rate is 110 beats per minute. Chest X-ray shows a left lower lobe infiltrate. The most appropriate initial treatment is
What is azithromycin (25)
200
A 39-year-old primigravid woman seeks nutritional advice at her first prenatal visit. Her sister had a fetal demise at 36 weeks of gestation that was attributed to infection with Listeria monocytogenes. She asks what foods she needs to avoid in order to decrease her risk of infection. You tell her that, in addition to avoiding unpasteurized food products, the type of food that she needs to avoid is
What is cold delicatessen meat (13)
200
A patient was treated with methotrexate for a suspected ectopic pregnancy. She returns to the clinic 4 weeks later with nausea and vomiting, breast tenderness, and a positive pregnancy test result. Ultrasonography reveals an intrauterine 10-week-sized fetus. As her physician, you inform her that methotrexate exposure during pregnancy is associated with
What is limb and cranial anomalies (16)
200
According to the 2011 Centers for Disease Control and Prevention recommendations, the use of combined oral contraceptives (OCs) can be safely started postpartum without contraindications at
What is 21 days (15)
200
A 21-year-old primiparous woman at term has had an uncomplicated labor. She achieved complete dilation 3 hours ago. She has been pushing with contractions since then and the fetal head has descended to 3 cm below the maternal ischial spines with some caput. The presenting position is left occiput anterior. The fetal heart rate tracing is Category I. Estimated fetal weight is 3,800 g. Her epidural analgesia is functioning well. The patient reports that she is completely exhausted and requests an operative vaginal delivery. In counseling this patient for operative vaginal delivery by vacuum, you should inform her that the most serious complication related to use of this procedure is
What is subgaleal hemorrhage (7)
300
A 36-year-old woman, gravida 1, para 0, at 32 weeks of gestation with known systemic lupus erythematosus (SLE) comes to your office for a routine prenatal visit. She has lupus nephritis with 2 g of protein in 24 hours. Her pregnancy has thus far proceeded normally although she has experienced mild arthritic symptoms with pain and discomfort in her joints. She has been taking no medication for her SLE other than nonsteroidal antiinflammatory drugs. She is now experiencing headache and increased pedal edema (+3). She is found to have hypertension (blood pressure 150/100 mm Hg) and her temperature is 38.1°C (100.6°F). Her laboratory results show a hemoglobin level 10.2 g/dL, platelet count 160,000/mm3, glucose level 98 mg/dL, and an increased 24-hour urinary protein of 4 g. Her levels of ammonia, liver enzymes, lactate dehydrogenase, and bilirubin are all in the normal range. The most likely diagnosis is
What is exacerbation of SLE (72)
300
A 26-year-old woman, gravida 3, is at 14 weeks of gestation. Both of her previous pregnancies resulted in a pregnancy loss in the second trimester. She also developed a pulmonary embolus during the postpartum period. She had positive test results for anticardiolipin antibody and lupus anticoagulant. In addition to administration of low-dose aspirin, the most appropriate medical therapy for her during pregnancy and the postpartum period is
What is heparin/lovenox (19)
300
A 32-year-old woman, gravida 3, para 2, at 22 weeks of gestation has a detailed fetal anatomic screen that reveals that her fetus has isolated bilateral cerebral ventriculomegaly. First-trimester risk assessment demonstrated a Down syndrome risk of 1:5,000 and a trisomy 18 risk of 1:10,000. Second-trimester alpha-fetoprotein (AFP) testing was 1.23 multiples of the median. There is no family history of ventriculomegaly. The toxoplasma serology result is negative, but cytomegalovirus (CMV) serology returns positive immunoglobulin G (IgG) and immunoglobulin M (IgM). The most sensitive and specific test for diagnosing fetal CMV infection is
What is amniocentesis for CMV DNA polymerase chain reaction (32)
300
A 25-year-old woman, gravida 1, para 1, had an uncomplicated vaginal delivery. At her 6-week postpartum visit, she tells you that she is worried about postpartum depression, which she has read about in a newspaper. She is currently without depressive symptoms and on no medications. In regard to the patient’s concern about postpartum depression, the best next step in management is
What is to screen with the Edinburgh Postnatal Depression Scale (23)
300
During a prenatal visit, a healthy 38-year-old primigravid woman asks about elective cesarean delivery. For personal reasons, she wants to plan her delivery to occur at 39 weeks of gestation.You review the relevant medical issues but are uncomfortable with agreeing to perform the cesarean delivery in the absence of a medical indication. The best option in this situation is to
What is refer her to another health care provider (14)
400
A 24-year-old primigravid woman at 39 weeks of gestation comes to the hospital in active labor. She requests epidural analgesia. Aside from hypotension, the most likely complication to be associated with her epidural anesthesia is
What is fever (64)
400
A 30-year-old woman, gravida 2, para 1, enrolls for prenatal care at 10 weeks of gestation and requests aneuploidy screening. The first-trimester ultrasonographic marker most likely to be clinically useful in screening for Down syndrome is
What is nuchal translucency (30)
400
A 32-year-old pregnant woman at 26 weeks of gestation comes to the labor and delivery unit with leakage of fluid. The fetal monitor shows a reassuring fetal heart rate tracing and no contractions. Sterile speculum examination reveals moderate clear fluid (nitrazine positive, ferning on microscopy) in the vagina with a closed cervix. On removal of the speculum, a cluster of 3 shallow ulcers are noted on the right labium. The patient reports that this is her usual location of herpes outbreaks and that she has experienced burning in that area for 24 hours. The best next step in management is
What is immediate antiviral therapy (42)
400
A 37-year-old woman, para 7, has just given birth to a vigorous infant. The placenta is delivered after fundal massage and cord traction. Heavy uterine bleeding ensues with a mass present at the introitus consistent with uterine inversion. The best next step in pharmacologic management is to prescribe
What is nitroglycerine (terbutaline or halogenated inhalation) (29)
400
A 31-year-old woman, gravida 3, para 2, comes to your clinic for a routine prenatal visit at 39 weeks of gestation. She enrolled late for prenatal care at 28 weeks of gestation. To date, she has had an uncomplicated pregnancy with normal weight gain, fetal growth, and laboratory testing. On examination, the fetus is in cephalic presentation and her cervix is favorable. She requests labor induction before her husband is deployed next week for military service. Amniocentesis is performed.Analysis of the blood-contaminated amniotic fluid shows a lecithin–sphingomyelin ratio of 1.7 and the presence of phosphatidylglycerol. The best management option for this patient is
What is immediate labor induction (17)
500
A 27-year-old woman, 2 weeks postpartum, comes to your office with fever and pain in the left breast. She has been exclusively breastfeeding since giving birth. She has no known drug allergies. Her temperature is 39°C (102°F). You observe a wedge-shaped area of redness and tenderness on the upper outer quadrant of the left breast and no discrete mass is palpated. The right breast is unremarkable. After 2 days of antibiotic therapy with dicloxacillin and no improvement, a breast milk culture reveals methicillin-resistant Staphylococcus aureus (MRSA). The best next step in pharmacotherapy is to prescribe
What is trimethoprim–sulfamethoxazole (clindamycin, tetracycline also acceptable) (66)
500
A 42-year-old white woman, gravida 1, comes to your office for her first prenatal visit at 12 weeks of gestation. She has no personal or family history of anemia. She is a vegan. Her prenatal laboratory results show a white blood count of 10,200/mm3, hemoglobin level 8.5 g/dL, hematocrit level 26.5%, and platelet count of 247,000/mm3. The mean corpuscular volume is 73 fL. Her serum ferritin level is 6 micrograms/L and her iron level is 23 micrograms/L. The best next step in her management is
What is prescribe oral iron (33)
500
A 34-year-old primigravid woman at 38 weeks of gestation comes to the hospital in active labor. She moved to the area recently and has not yet established prenatal care in your office. Her previous obstetrician called to inform her that her genital culture at 36 weeks of gestation was positive for group B streptococci (GBS). She has a penicillin allergy, which she describes as a diffuse itchy raised rash (hives). The best antibiotic to use for GBS prophylaxis during her labor is
What is cefazolin (44)
500
During a postpartum hemorrhage, enveloping and compressing the fundus with suture to provide mechanical pressure for a prolonged period is known as a
What is a B-Lynch suture (31)
500
A patient presents at 24 weeks of gestation in active labor with a cervical dilation of 8 cm and breech presentation. You deem that delivery is imminent and that cesarean delivery would be the best option for the fetus. The fetal factor that is most predictive of the survival of the preterm newborn is
what is gestational age (21)