All practice questions

An obstetrician is called to evaluate a $27$-year-old primigravida at $36$ weeks gestation in the labor and delivery unit due to acute respiratory difficulty. She was admitted four hours ago for preeclampsia with severe features, presenting with a blood pressure of $170/110\text{ mmHg}$, new-onset visual scotomata, and proteinuria. An intravenous magnesium sulfate infusion was initiated for seizure prophylaxis. Over the last $30$ minutes, she has developed significant difficulty swallowing, blurred vision, bilateral ptosis, and profound generalized muscle weakness. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $150/95\text{ mmHg}$, heart rate is $92/\text{min}$, and respiratory rate is $10/\text{min}$ with shallow efforts. Pulse oximetry is $91\%$ on room air. Physical examination reveals weak neck flexion. Patellar reflexes are $2+$ bilaterally. Urine output over the last $4$ hours has been $220\text{ mL}$. Continuous fetal heart rate monitoring demonstrates a baseline of $140/\text{min}$ with moderate variability and no decelerations.

Which of the following is the most appropriate next step in management?

A 12-day-old girl is brought to the emergency department by her parents due to two days of worsening vomiting, hypotonia, and decreased responsiveness. She was born at 39 weeks gestation and was feeding well on standard infant formula until this episode. Her temperature is 36.5°C (97.7°F), heart rate is 170/min, and respiratory rate is 68/min with deep, rapid breaths. Physical examination shows a lethargic neonate with dry mucous membranes and decreased muscle tone.

Laboratory studies show the following:

Arterial blood gas analysis on room air shows a pH of 7.20 and a $pCO_2$ of 23 mm Hg. Urinalysis demonstrates large ketones but is negative for reducing substances. Further metabolic testing reveals markedly elevated serum propionic acid and methylcitric acid levels, with normal methylmalonic acid levels.

Which of the following is the most appropriate specific long-term dietary management for this patient's underlying condition?

A $32$-year-old woman, gravida $3$, para $2$, at $34$ weeks gestation comes to the clinic for a routine evaluation. She reports feeling more fatigued over the past two weeks, along with mild shortness of breath when climbing the stairs at her home. She occasionally notices her heart beating faster than usual. She reports good fetal movement and denies chest pain, cough, or orthopnea. Her past medical history is unremarkable. Blood pressure is $110/64$ mm Hg, pulse is $104$/min, and respirations are $18$/min. Pulse oximetry shows $98\%$ on room air. Physical examination reveals clear lungs bilaterally. Cardiac auscultation shows a grade $2/6$ systolic ejection murmur best heard at the left sternal border without radiation. Trace bilateral pitting edema is present at the ankles.

Laboratory and diagnostic studies show the following:
Hemoglobin: $11.2$ g/dL
Hematocrit: $33\%$
Platelet count: $185,000/\text{mm}^3$
Serum creatinine: $0.5$ mg/dL

Arterial blood gas (room air):
pH: $7.45$
$\text{PaCO}_2$: $29$ mm Hg
$\text{PaO}_2$: $102$ mm Hg
$\text{HCO}_3^-$: $20$ mEq/L

An electrocardiogram demonstrates normal sinus rhythm with left axis deviation.

Which of the following is the most appropriate next step in the management of this patient?

An 18-year-old nulliparous patient at 38 weeks gestation is evaluated on the labor and delivery unit. She was admitted in active labor, and artificial rupture of membranes was performed two hours ago. Her temperature is 37.0°C (98.6°F) and blood pressure is 110/70 mmHg. Cervical examination shows 7 cm dilation, 100% effacement, and the fetal vertex at +1 station. The external fetal monitor shows a baseline heart rate of 145/min with moderate variability. During the monitoring period, the fetal heart rate frequently exhibits abrupt decreases to 85/min. These decreases reach their nadir within 15 seconds of onset, last for roughly 45 seconds, and rapidly return to the baseline of 145/min. These episodes occur during the majority of her uterine contractions. Which of the following is the most appropriate initial step in management?

A 29-year-old multiparous patient at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her cervix is 5 cm dilated and 100% effaced, with the fetal vertex at -2 station. Thirty minutes later, she experiences a spontaneous gush of clear vaginal fluid. Immediately following this event, the electronic fetal monitor demonstrates a sudden, prolonged drop in the fetal heart rate to 70/min lasting for over 3 minutes. A sterile vaginal examination reveals a palpable, pulsating rope-like mass in the vaginal canal ahead of the fetal presenting part. Which of the following is the most appropriate immediate step in management?

Match each pediatric cardiovascular clinical presentation with its most appropriate targeted therapeutic intervention.

An 8-month-old male infant presents for a routine wellness examination accompanied by his parents. The family is anxious because the child is not yet walking on his own and has not started speaking in two-word sentences. Upon physical evaluation, the clinician notes that the infant exclusively uses his right hand to grasp objects while keeping his left hand tightly clenched. Neurological assessment demonstrates increased muscle tone and hyperactive deep tendon reflexes in the left upper and lower extremities. A review of his past medical history reveals he was delivered prematurely at 29 weeks of gestation. The clinician suspects spastic hemiplegic cerebral palsy. Which of the following statements regarding this patient's clinical presentation and appropriate management are correct? (Select 2)

Match each clinical presentation of postpartum hemorrhage with its most likely underlying obstetric etiology.

An expectant mother at $31$ weeks of gestation arrives at the obstetric clinic for a routine assessment. The $27$-year-old patient notes that over the past few weeks, her shoes have felt tight by the evening and she experiences mild dyspnea after walking up a single flight of stairs. She denies headaches, visual disturbances, and right upper quadrant abdominal pain. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $116/74\text{ mm Hg}$, pulse $96/\text{min}$, and respirations $18/\text{min}$. Physical examination reveals a point of maximal impulse that is displaced upward and to the left. Cardiac auscultation demonstrates an early systolic murmur (grade $2/6$) at the left sternal border and an audible third heart sound ($S_3$). Lungs are clear to auscultation bilaterally. The lower extremities show $1+$ bilateral pitting edema. Laboratory evaluation reveals the following:

Leukocyte count: $13,500/\text{mm}^3$
Hemoglobin: $11.2\text{ g/dL}$
Platelet count: $155,000/\text{mm}^3$
Serum creatinine: $0.5\text{ mg/dL}$

Urine dipstick is negative for protein. Which of the following is the most appropriate action for this patient's current presentation?

A 4-day-old term female infant is brought to the emergency department by her parents due to multiple episodes of green-tinged vomiting that began 6 hours ago. She has been exclusively breastfed and previously had normal stooling and wet diapers. Her temperature is 37.1°C (98.8°F), heart rate is 148/min, respiratory rate is 42/min, and blood pressure is 76/42 mm Hg. Physical examination reveals a soft, non-distended, and non-tender abdomen with active bowel sounds. Capillary refill time is 2 seconds. Arrange the following steps in the most appropriate sequence for the evaluation and management of this patient, from the first step to the definitive final step.

A 34-year-old G4P3 woman experiences massive postpartum hemorrhage due to uterine atony immediately following an uncomplicated vaginal delivery of a 4100-g (9 lb) neonate. Despite the administration of continuous intravenous oxytocin and vigorous bimanual uterine massage, profuse vaginal bleeding persists. Her blood pressure decreases to 76/40 mm Hg and her heart rate increases to 132/min. Assuming each successive intervention fails to arrest the hemorrhage, arrange the following management steps in the correct escalating sequence according to standard obstetric protocols.

A 32-year-old pregnant woman, gravida 2, para 1, is admitted to the labor and delivery unit at 39 weeks gestation in active labor. Her pregnancy has been uncomplicated. Her pulse is 86/min and blood pressure is 118/76 mm Hg. Pelvic examination reveals the cervix is 7 cm dilated and 90% effaced, with the fetal vertex at 0 station. Artificial rupture of membranes is performed to facilitate internal fetal monitoring, yielding clear amniotic fluid. Thirty minutes later, the fetal heart rate tracing demonstrates a baseline of 145/min with moderate variability. However, there are recurrent, abrupt decreases in the fetal heart rate to 90/min that last for 30 to 45 seconds before rapidly returning to the baseline. The nadir of these decelerations occurs less than 30 seconds after their onset. The nurse immediately repositions the patient into the left lateral decubitus position and administers a bolus of intravenous normal saline, but the fetal heart rate pattern persists over the next three contractions. Which of the following is the most appropriate next step in management?

Match each classic clinical presentation and associated diagnostic imaging finding with the most appropriate pediatric gastrointestinal diagnosis.

During a visit to the urgent care clinic, a 21-year-old college student describes experiencing deep, aching lower pelvic pain that has progressively worsened over the past three days. She also reports noticing blood on her toilet tissue between her regular menstrual cycles. She has had two new sexual partners in the last six months and uses oral contraceptives inconsistently. Her vital signs show a temperature of 38.3°C (100.9°F), a heart rate of 98/min, and a blood pressure of 112/72 mm Hg. Palpation of the lower abdomen elicits tenderness without guarding. A speculum examination reveals a friable cervix with thick, yellow exudate at the os. During the bimanual exam, the patient vocalizes significant pain when the cervix is mobilized laterally, and both adnexa are tender to palpation, though no discrete masses are felt. A point-of-care pregnancy test is negative. In addition to obtaining samples for nucleic acid amplification testing, which of the following is the most appropriate next step in the management of this patient?

Paramedics bring a $9$-year-old girl to the emergency department due to acute-onset, severe shortness of breath. She has a history of moderate persistent asthma but exhausted her supply of inhaled fluticasone-salmeterol two months ago. Her symptoms began abruptly after she visited a relative's house that has multiple indoor cats. In the emergency department, she receives three continuous nebulized treatments of albuterol and ipratropium, along with a dose of intravenous methylprednisolone. Reassessment $45$ minutes later reveals a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate of $148/\text{min}$, and respiratory rate of $38/\text{min}$. Pulse oximetry is $91\%$ on a $4\text{ L/min}$ nasal cannula. On examination, the patient appears exhausted and somnolent. She is sitting in a tripod position and using prominent suprasternal and intercostal accessory muscles to breathe. Chest auscultation reveals a "silent chest" with markedly diminished air entry bilaterally and no audible wheezing. Arterial blood gas analysis on supplemental oxygen reveals a $\text{pH}$ of $7.31$, $\text{PaCO}_2$ of $46 \text{ mmHg}$, and $\text{PaO}_2$ of $62 \text{ mmHg}$. Which of the following is the most appropriate next step in management?

Match each specific gestational age window during a normal pregnancy to the corresponding routine prenatal screening test or intervention that is optimally performed during that timeframe.

While waiting in the obstetric triage area, a primigravida at $38$ weeks of gestation abruptly loses consciousness and exhibits generalized tonic-clonic motor activity. Moments prior to this event, she had complained of a severe, unrelenting headache and seeing 'flashing lights'. Her last recorded blood pressure, taken ten minutes earlier, was $185/115\text{ mmHg}$. During the convulsion, the continuous external fetal monitor records a sudden, prolonged drop in the fetal heart rate to $65\text{/min}$.

Arrange the following critical management steps in the correct chronological sequence to appropriately address this acute emergency.

Match each etiology of primary postpartum hemorrhage with its classic physical examination finding or clinical presentation.

A $4$-day-old male infant born at term is admitted to the neonatal intensive care unit with progressive lethargy, hypothermia, and poor feeding over the past $24$ hours. Physical examination reveals a somnolent neonate with profound hypotonia and tachypnea. Initial laboratory studies show a severe respiratory alkalosis and a serum ammonia level of $1,250 \mu\text{mol/L}$ (normal: $15$-$50 \mu\text{mol/L}$). There is no metabolic acidosis or ketosis. The clinical team suspects a urea cycle disorder and recognizes a severe hyperammonemic crisis. Arrange the following interventions in the most appropriate chronological sequence for the acute management of this patient.

A 31-year-old gravida 2, para 1 at 39 weeks and 4 days gestation is evaluated on the labor and delivery unit. Her prenatal course was uncomplicated. She is currently in the second stage of labor and has been actively pushing for 45 minutes with adequate epidural analgesia. The cervix is completely dilated and 100% effaced. The fetal presenting part is the vertex in the direct occiput anterior position at +3 station. Maternal vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and a heart rate of 88/min. Uterine contractions are occurring every 3 minutes. Over the past 5 minutes, the continuous fetal heart rate monitor demonstrates an abrupt decrease in the baseline to 75/min with absent variability and no return to the previous baseline of 145/min. Immediate repositioning of the patient to the left lateral decubitus position and administration of an intravenous normal saline bolus do not improve the tracing. Which of the following is the most appropriate next step in management?