All practice questions

A 22-year-old nulliparous woman presents to the labor unit at 38 weeks and 5 days of gestation complaining of intense, frequent contractions. Her prenatal care has been routine and uncomplicated. Vital signs are within normal limits, with a blood pressure of 118/74 mmHg and a heart rate of 88/min. She declines epidural analgesia. On digital cervical examination, she is 6 cm dilated and 100% effaced, and the fetal vertex is at 0 station. There is no evidence of vaginal bleeding.

Electronic fetal monitoring demonstrates a baseline heart rate of 145/min with minimal variability. The tocodynamometer records 7 to 8 uterine contractions per 10-minute window. Each contraction lasts approximately 80 seconds, though the uterus is soft to palpation between contractions. Symmetrical, gradual decreases in the fetal heart rate that reach their nadir after the peak of the contraction are seen repeatedly. In response, the clinical team implements left lateral maternal positioning, administers a rapid intravenous fluid bolus, and provides supplemental oxygen. Fifteen minutes later, the high contraction frequency and the abnormal fetal heart rate pattern persist.

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

An $11$-month-old boy is rushed to the emergency department due to a sudden episode of severe cyanosis and unresponsiveness. The parents report that the child became extremely agitated and inconsolable during a blood draw at a local clinic, after which his lips and fingers turned deep blue. He has a history of an uncorrected congenital heart defect for which he is awaiting surgical repair. On arrival, the child is lethargic. Vital signs show a heart rate of $175/\text{min}$, respiratory rate of $55/\text{min}$, and oxygen saturation of $65\%$ on room air. Physical examination reveals a harsh, grade 4/6 systolic ejection murmur at the left mid-to-upper sternal border and a single S2. The emergency physician immediately places the infant in a knee-chest position and applies $100\%$ supplemental oxygen via a non-rebreather mask. Intravenous morphine and a normal saline bolus are administered. Ten minutes later, the infant's oxygen saturation remains at $68\%$. Which of the following is the most appropriate next pharmacologic intervention and its primary physiologic mechanism in this patient?

A 31-year-old gravida 2, para 1 woman at 35 weeks gestation is brought to the emergency department due to sudden-onset, severe, continuous abdominal pain and moderate dark vaginal bleeding. Her pregnancy is complicated by chronic hypertension, for which she takes labetalol. Her blood pressure is 165/100 mm Hg, and her pulse is 115/min. On physical examination, the uterus is hypertonic, rigid, and exquisitely tender to palpation. Fetal monitoring reveals a baseline heart rate of 165/min with minimal variability and recurrent late decelerations. The tocodynamometer demonstrates high-frequency, low-amplitude contractions. Maternal repositioning, supplemental oxygen, and an intravenous fluid bolus have been administered, but the fetal heart rate tracing remains unchanged. Which of the following is the most appropriate next step in management?

A 27-year-old primigravida presents for her initial prenatal visit at 8 weeks gestation. Her blood type is subsequently confirmed to be O, Rh(D)-negative. She experiences an uncomplicated pregnancy and delivers a healthy, Rh(D)-positive infant at 39 weeks gestation. A routine postpartum screening test indicates the presence of a significant fetomaternal hemorrhage. Arrange the following clinical steps regarding her Rh(D) management in the standard chronological sequence required to evaluate and prevent maternal alloimmunization, from the first trimester through her postpartum care.

A 48-hour-old full-term male neonate is evaluated in the nursery because he has not yet passed meconium. The nurses report that the infant has had three episodes of bilious vomiting in the past 12 hours. On physical examination, the infant's abdomen is visibly distended and tympanitic. During a digital rectal examination, there is an explosive release of gas and foul-smelling stool, after which the abdomen becomes notably less distended. Which of the following is the most likely underlying pathophysiology of this patient's presentation?

A 9-month-old boy arrives at the emergency department accompanied by his parents after a frightening episode at home. His mother reports that while he was crying vigorously during a diaper change, his lips, hands, and feet suddenly turned a deep blue color, and he appeared unusually limp. The mother instinctively held him tightly with his knees tucked against his chest, and his normal skin color slowly returned over 15 minutes. The infant was diagnosed with a heart murmur in the neonatal nursery but missed his scheduled cardiology follow-up. Current vital signs are temperature 37.0°C (98.6°F), heart rate 138/min, respiratory rate 32/min, and blood pressure 94/56 mm Hg. Oxygen saturation is 93% on room air. Cardiac auscultation reveals a prominent right ventricular heave, a single S2, and a grade 3/6 harsh, crescendo-decrescendo systolic murmur heard best at the left mid-to-upper sternal border. The remainder of the physical examination is unremarkable. If a similar hypercyanotic episode occurs during evaluation and fails to improve with supplemental oxygen and knee-chest positioning, which of the following is the most appropriate next pharmacologic step in management?

A 24-year-old primigravid woman at 39 weeks gestation is evaluated on the labor and delivery unit. She is in spontaneous active labor following an uncomplicated prenatal course. Her temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Cervical examination reveals 7 cm dilation, 100% effacement, and +1 station. Continuous electronic fetal monitoring demonstrates a baseline heart rate of 145/min with moderate variability. There are periodic, symmetric, gradual decreases in the fetal heart rate that begin exactly as the uterine contractions start, reach their nadir at the peak of the contractions, and return to baseline as the contractions end. The lowest heart rate recorded during these episodes is 125/min. What is the most appropriate next step in the management of this patient?

A 7-year-old boy with a history of moderate persistent asthma is brought to the emergency department for severe shortness of breath. He is speaking in single words, sitting in a tripod position, and using accessory muscles to breathe. Physical examination reveals diffuse expiratory wheezing and a prolonged expiratory phase. His oxygen saturation is 88% on room air. Arrange the following steps in the most appropriate sequential order for the acute management of this patient.

Identify the most likely underlying obstetric complication for each of the following acute intrapartum or postpartum presentations.

A 45-year-old woman is evaluated in the clinic for persistent vaginal symptoms. Three weeks ago, she presented with a profuse, malodorous, yellowish-green vaginal discharge and severe vulvar pruritus. At that time, speculum examination revealed punctate macular hemorrhages on the ectocervix. A saline wet mount confirmed the presence of motile, flagellated organisms with multiple polymorphonuclear leukocytes. The vaginal pH was $6.5$. She was prescribed a $7$-day course of oral metronidazole, $500$ mg twice daily. During today's visit, she reports that her symptoms briefly improved but completely returned five days ago. The patient confirms strict adherence to the prescribed medication regimen and states she has abstained from all sexual contact since before her initial visit. Her medical history is otherwise unremarkable. Repeat saline microscopy of the discharge today demonstrates the same motile organisms seen previously. Which of the following is the most appropriate next step in management?

A 5-year-old boy is brought to the emergency department by his parents due to extreme fatigue, decreased urination over the past 24 hours, and a new rash. One week ago, he had a 3-day episode of severe, bloody diarrhea accompanied by abdominal cramps, which was treated with oral ciprofloxacin at an urgent care clinic. Today, he appears pale and lethargic. Vitals show a temperature of $37.2^\circ\text{C}$, heart rate of $135/\text{min}$, respiratory rate of $24/\text{min}$, and blood pressure of $118/78 \text{ mmHg}$. Physical examination reveals scleral icterus and scattered petechiae over the lower extremities. The abdomen is soft and non-tender with no hepatosplenomegaly. Laboratory studies show:

A peripheral blood smear demonstrates numerous fragmented red blood cells. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old gravida 1 para 0 woman at 39 weeks gestation is admitted to the labor and delivery unit in active labor. Her prenatal course has been uncomplicated. Cervical examination reveals 6 cm dilation, 100% effacement, and 0 fetal station. The patient requests analgesia, and a lumbar epidural is placed. Fifteen minutes later, she reports the sudden onset of nausea and lightheadedness. Her temperature is 37.1°C (98.8°F), blood pressure is 80/45 mm Hg, and heart rate is 118/min. Prior to the epidural, continuous fetal monitoring demonstrated a baseline of 140/min with moderate variability and no decelerations. Currently, the monitor shows a sudden decrease in the fetal heart rate to 85/min that has persisted for the past 4 minutes. Uterine contractions are occurring every 3 to 4 minutes. The patient is immediately repositioned to the left lateral decubitus position and an intravenous normal saline bolus is initiated, but the maternal blood pressure remains low and the fetal heart rate remains at 85/min. Which of the following is the most appropriate next step in management?

During a busy winter shift at the pediatric emergency department, a $6$-week-old female infant is triaged for severe respiratory distress. The parents describe a prodrome of clear rhinorrhea and a mild cough that began $4$ days prior. However, since this morning, she has been refusing to feed and appears to be struggling for each breath. She was born via spontaneous vaginal delivery at $39$ weeks gestation with an uncomplicated postnatal course.

Vital signs are as follows:
- Temperature: $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$)
- Heart rate: $172$/min
- Respiratory rate: $70$/min
- Blood pressure: $85/50$ mm Hg
- Oxygen saturation: $85\%$ on room air

Physical examination reveals an ill-appearing infant with marked head bobbing, severe intercostal and subcostal retractions, and prominent nasal flaring. Lung auscultation demonstrates bilateral diffuse fine crackles and high-pitched expiratory wheezing. Capillary refill time is $3$ seconds.

Which of the following therapies are currently indicated for this patient? (Select all that apply)

A nulligravid 24-year-old female is evaluated in the emergency department for a 3-day history of progressively worsening lower pelvic pain, severe nausea, and subjective fevers. She reports having a new sexual partner over the past 2 months and admits to inconsistent barrier protection. Her temperature is 38.9°C (102.0°F), blood pressure is 100/60 mm Hg, and pulse is 112/min. Physical examination demonstrates marked bilateral lower quadrant tenderness with involuntary guarding. Speculum examination reveals a purulent endocervical exudate. Bimanual examination elicits severe cervical motion tenderness and reveals a palpable, exquisitely tender 6-cm right adnexal fullness.

Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

Correctly map each pediatric patient's specific clinical vignette to the corresponding underlying biochemical or genetic defect.

A 14-year-old boy is evaluated in the pediatric neurology clinic due to a 1-year history of progressive difficulty walking. He reports feeling unsteady and frequently trips over his own feet, especially in the dark. His parents note that his handwriting has become increasingly messy over the past few months. His early motor and language milestones were achieved at the appropriate ages. Vital signs are within normal limits. Neurological examination reveals a wide-based gait. When asked to stand with his feet together and eyes closed, he sways significantly and requires assistance to maintain his balance. Muscle strength is 5/5 in all extremities, but deep tendon reflexes are absent at the knees and ankles. Sensation to vibration and joint position is markedly diminished in the toes. Musculoskeletal examination is notable for bilateral high plantar arches and a lateral curvature of the thoracic spine. Which of the following is the most important next step in evaluation to screen for the most common cause of mortality in this condition?

A 9-month-old infant with a known, uncorrected congenital cardiac anomaly is evaluated in the pediatric triage area. His father reports that after waking up from a nap and crying vigorously, the infant's skin became notably dusky and he stopped responding to his name. Triage vital signs show a heart rate of 170/min and an oxygen saturation of 65% on room air. A harsh, crescendo-decrescendo systolic ejection murmur is prominent at the left upper sternal border. The child is currently extremely agitated, inconsolable, and tachypneic.

Arrange the following interventions in the correct chronological sequence for managing this patient's acute presentation, starting with the initial non-invasive bedside action and progressing to escalating pharmacologic steps for refractory symptoms.

A term female neonate, born at 39 weeks gestation via uncomplicated vaginal delivery, is evaluated in the nursery at 6 hours of life due to worsening central cyanosis. Her oxygen saturation is $68\%$ on room air. After receiving $100\%$ supplemental oxygen via hood for 15 minutes, her oxygen saturation only increases to $70\%$. Physical examination reveals a respiratory rate of $62/\text{min}$, equal and strong pulses in all four extremities, a prominent right ventricular impulse, and a loud, single second heart sound ($S_2$) without an appreciable murmur. Assuming the patient is ultimately found to have inadequate interatrial mixing upon diagnostic evaluation, arrange the following management steps in the most appropriate chronological sequence from initial emergency intervention to definitive treatment.

Emergency medical personnel transport an 18-month-old boy to the emergency department due to progressive lethargy and severe pallor over the past 12 hours. The patient has a known history of sickle cell disease (HbSS) and is currently prescribed daily penicillin prophylaxis. Upon arrival, his temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), heart rate is $172/\text{min}$, respiratory rate is $44/\text{min}$, and blood pressure is $65/35\text{ mm Hg}$. Physical examination reveals a somnolent toddler with marked conjunctival pallor, delayed capillary refill of 4 seconds, and cool, clammy extremities. Abdominal examination demonstrates significant distension and a firm, tender mass extending $6\text{ cm}$ below the left costal margin. Laboratory studies reveal the following:

* Hemoglobin: $3.8\text{ g/dL}$ (baseline $8.2\text{ g/dL}$)
* Reticulocytes: $16\%$
* Platelets: $45,000/\text{mm}^3$
* Leukocytes: $14,000/\text{mm}^3$

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

A 27-year-old nulligravid woman is admitted to the gynecology service with worsening lower abdominal pain, chills, and purulent vaginal discharge over the past three days. Her temperature is 38.8°C (101.8°F), blood pressure is 115/75 mm Hg, and pulse is 98/min. Pelvic examination reveals significant cervical motion tenderness and a palpable, tender left adnexal mass. A transvaginal ultrasound demonstrates a 7-cm complex, multiloculated left adnexal fluid collection consistent with a tubo-ovarian abscess. There is no free fluid in the cul-de-sac. The patient is hemodynamically stable and has a soft abdomen with normal bowel sounds. Arrange the following steps in the most appropriate chronological order for the standard evidence-based management of this patient's condition.