All practice questions

A 24-year-old primigravid woman at 39 weeks and 2 days gestation is evaluated in the labor and delivery unit due to a non-reassuring fetal heart rate tracing. The patient presented in spontaneous active labor 14 hours ago and has been pushing in the second stage of labor for 2.5 hours. Continuous epidural anesthesia provides excellent pain relief. Over the last 15 minutes, the continuous fetal monitor demonstrates a baseline heart rate of 155/min, absent baseline variability, and recurrent late decelerations. Uterine contractions occur every 3 minutes, last 60 seconds, and are palpated as firm. The nursing staff immediately repositioned the patient to the left lateral decubitus position, administered an intravenous fluid bolus, and applied 100% oxygen via a nonrebreather mask. Subsequent evaluation 10 minutes later shows no improvement in the fetal heart rate tracing. Maternal vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $118/74$ mm Hg, and pulse 92/min. On physical examination, the cervix is completely dilated and effaced. The fetal sagittal suture is palpable in the anteroposterior diameter with the posterior fontanelle directed anteriorly. The leading bony edge of the fetal skull is at $+3$ station. Which of the following is the most appropriate next step in management?

A 21-year-old nulligravid woman presents to the emergency department with a 3-day history of progressively worsening lower abdominal pain, fever, and vomiting. She states she has been unable to tolerate any oral intake today. Her temperature is 39.1°C (102.4°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Pelvic examination is notable for copious yellow cervical discharge, severe cervical motion tenderness, and a palpable, exquisitely tender 7-cm mass in the left adnexa. Arrange the following steps in the most appropriate chronological sequence for the evaluation and management of this patient.

A 6-year-old girl is evaluated in the emergency department due to a 2-day history of progressively worsening back pain and new-onset difficulty walking. She has not voided urine for the past 14 hours. The patient was diagnosed with stage IV neuroblastoma 8 months ago and is currently receiving systemic chemotherapy. Temperature is 37.0°C (98.6°F), heart rate is 112/min, and blood pressure is 108/68 mm Hg. Physical examination reveals 3/5 muscle strength in bilateral lower extremities, patellar hyperreflexia, and decreased sensation to pinprick below the umbilicus. A palpable, distended bladder is noted. Suspecting an acute oncologic emergency, arrange the following management steps in the most appropriate chronological order from first to last.

A clinical geneticist is discussing screening and prophylactic strategies with several women who have strong family histories of malignancy. For each described genetic mutation and associated gynecologic cancer risk profile, identify the correct corresponding hereditary syndrome.

Match each pregnant patient scenario with the most appropriate routine screening test or laboratory evaluation indicated at their current gestational age.

A 5-month-old girl, born at 34 weeks of gestation, is brought to the emergency department in mid-winter by her parents due to a worsening cough and rapid breathing for the past 48 hours. Her symptoms began four days ago with a runny nose and a low-grade fever. The parents report she has been too tired to feed and has had only one wet diaper since yesterday evening.

On physical examination, her temperature is 37.9°C (100.2°F), heart rate is 170/min, respiratory rate is 72/min, and oxygen saturation is 86% on room air. The infant appears lethargic and is grunting. There is significant nasal flaring, as well as marked subcostal and intercostal retractions. Auscultation of the lungs reveals diffuse coarse crackles and prominent expiratory wheezing bilaterally.

Which of the following interventions are appropriate in the immediate management of this patient? (Select all that apply)

A 6-year-old girl is brought to the pediatric emergency department via ambulance due to a prolonged seizure. The parents report that she started having generalized tonic-clonic movements 15 minutes ago, which have been continuous since onset. She has no prior history of seizures. On arrival, she is unresponsive and actively convulsing. Her vital signs are temperature 37.8°C (100°F), blood pressure 110/70 mm Hg, pulse 145/min, and respirations 24/min. Paramedics were unable to establish intravenous access during transport.

Arrange the following management steps in the most appropriate chronological order for this patient.

Match each pediatric clinical presentation to the congenital cardiovascular anomaly most classically associated with the underlying condition.

A 68-year-old man is brought to the emergency department from a nursing facility due to fever, cough, and progressive lethargy over the past 2 days. His medical history is significant for chronic kidney disease, hypertension, and benign prostatic hyperplasia. Temperature is 38.8°C (101.8°F), blood pressure is 88/54 mm Hg, pulse is 112/min, and respiratory rate is 22/min with shallow breathing. Physical examination reveals crackles in the right lower lung base and delayed capillary refill. The patient is somnolent and only arouses to painful stimuli.

Arterial blood gas (room air):
- pH: 7.08
- $pCO_2$: 35 mm Hg
- $pO_2$: 65 mm Hg

Serum chemistries:
- Sodium: 138 mEq/L
- Potassium: 4.5 mEq/L
- Chloride: 102 mEq/L
- Bicarbonate: 10 mEq/L
- Blood urea nitrogen: 45 mg/dL
- Creatinine: 2.8 mg/dL
- Lactate: 5.2 mmol/L (Normal 0.5-1.5 mmol/L)

Which of the following best characterizes this patient's current acid-base status?

A 72-year-old resident of an assisted living facility is brought to the gynecology clinic by her daughter due to the recent discovery of blood-stained undergarments. The daughter noticed the spotting on three separate occasions over the past month. The patient has a medical history of mild Alzheimer dementia and hypertension, and she denies any abdominal or pelvic pain. Vital signs are within normal limits. On physical examination, the physician notes mild anterior vaginal wall prolapse and a smooth, 1.5-cm red, friable mass protruding through the external cervical os. A transvaginal ultrasound is performed during the visit, demonstrating normal-appearing ovaries and an endometrial thickness of 8 mm. Which of the following is the most appropriate next step in the management of this patient?

Presenting to a community health clinic, a 24-year-old female college student complains of a bilateral lower pelvic ache and abnormal vaginal spotting that began four days ago. She denies nausea, vomiting, or recent fever. Her medical history is unremarkable, and she uses a hormonal etonogestrel subdermal implant for contraception. She reports having a new male partner for the past month and inconsistent barrier protection use. Vital signs reveal a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mm Hg, and heart rate of 78/min. Abdominal palpation elicits mild discomfort in the bilateral lower quadrants without guarding or rebound. During the pelvic examination, a mucopurulent discharge is noted at the cervical os, and the cervix bleeds easily upon swabbing. Bimanual examination demonstrates pronounced tenderness upon cervical motion as well as bilateral adnexal tenderness. No adnexal masses are palpable. A rapid point-of-care pregnancy test is negative. Which of the following is the most appropriate next step in the management of this patient?

A 16-year-old girl is evaluated in the clinic for absence of menarche. She reports no cyclic pelvic or abdominal pain. She has experienced normal growth spurts, and her 14-year-old sister began menstruating a year ago. She takes no medications and has no significant past medical history. Vital signs are within normal limits. On physical examination, height is at the 65th percentile and weight is at the 60th percentile. Breast development is Tanner stage 4, and pubic and axillary hair are Tanner stage 4. Pelvic examination reveals normal female external genitalia and a shortened, 3-cm blind-ending vaginal pouch. Transabdominal ultrasonography reveals the absence of a uterus and cervix, but symmetric, morphologically normal ovaries are visualized. Laboratory evaluation shows a serum testosterone concentration of 40 ng/dL (reference range for females: 15-70 ng/dL). Karyotype analysis reveals a 46,XX chromosomal pattern. Which of the following is the most appropriate next step in the management of this patient?

During a parent-teacher conference, a first-grade educator expresses concern regarding a 7-year-old student's classroom behavior. The teacher notes that the child frequently halts his activities, stares into space with intermittent eyelid fluttering, and remains entirely unresponsive to verbal prompts for approximately 10 to 15 seconds. Following these brief interruptions, he immediately resumes his tasks with no apparent awareness of the pause. The student's father brings him to an outpatient clinic for evaluation. The father reports that his son has always met developmental expectations and performs well academically overall. The patient's vital signs are within normal limits. A comprehensive neurologic examination reveals no focal deficits.

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

Following an uncomplicated term pregnancy, a patient is admitted to the labor unit in the active phase of the first stage of labor. After receiving epidural anesthesia for pain management, she begins to complain of dizziness and nausea. Her current vital signs show a blood pressure of $82/48$ mmHg and a heart rate of $110$/min. Continuous electronic fetal monitoring reveals a baseline heart rate of $130$/min with moderate variability. The tracing also demonstrates recurrent, gradual, and symmetric decreases in the fetal heart rate that begin after the peak of each uterine contraction and resolve only after the contraction has completely finished. Which of the following is the most appropriate initial management step?

During a routine health maintenance visit, a 9-year-old male is evaluated by a new family physician. His parents mention that he frequently stops to rest while playing outdoors with friends, complaining that his legs ache and feel weak. He has no history of significant illnesses and takes no daily medications. His vital signs show a temperature of 36.8°C (98.2°F), a heart rate of 82/min, and a respiratory rate of 18/min. Measurement of his blood pressure yields 146/92 mm Hg in the right upper extremity and 144/90 mm Hg in the left upper extremity. Upon further examination, simultaneous palpation reveals that his femoral pulses are significantly diminished in amplitude and temporally delayed compared to his brachial pulses. Auscultation of the heart demonstrates a regular rhythm without extra heart sounds, but a grade 2/6 systolic ejection murmur is audible over the left interscapular region. Which of the following findings is most likely to be present on further evaluation of this patient?

A $7$-year-old girl is evaluated in the pediatric emergency department for severe abdominal pain and vomiting. She underwent a laparoscopic appendectomy for perforated appendicitis $6$ days ago and was discharged home on postoperative day $3$. Over the past $12$ hours, she has developed intense, colicky abdominal pain and repeated episodes of bilious emesis. Her parents note she has not passed stool or flatus since yesterday. On presentation, the child appears toxic, pale, and lethargic. Vital signs reveal a temperature of $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$), heart rate of $145\text{/min}$, respiratory rate of $30\text{/min}$, and blood pressure of $85/50\text{ mm Hg}$. Physical examination demonstrates a markedly distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of $22,000/\text{mm}^3$ with a left shift and a serum lactate of $4.6\text{ mmol/L}$. An upright plain radiograph of the abdomen reveals multiple dilated loops of small intestine with prominent air-fluid levels and a paucity of colonic gas. Following the initiation of aggressive intravenous fluid resuscitation, which of the following is the most appropriate next step in the management of this patient?

A $28$-month-old boy is brought to the emergency department late in the evening due to noisy breathing that began abruptly. His parents report that he had a mild subjective fever and nasal congestion for the past $3$ days. Earlier tonight, he awoke from sleep with a harsh, barking cough and severe respiratory distress. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), pulse is $140/\text{min}$, respirations are $42/\text{min}$, and pulse oximetry is $95\%$ on room air. The patient is sitting upright on his mother's lap and appears highly anxious. Physical examination reveals high-pitched inspiratory sounds audible without a stethoscope, along with pronounced suprasternal and intercostal retractions. Auscultation of the lungs demonstrates referred upper airway noise but no focal wheezes or crackles. The oropharynx is clear without excessive drooling. Which of the following is the most appropriate next step in management?

An otherwise healthy $24$-year-old nulliparous woman comes to the obstetric clinic at $29$ weeks gestation for a scheduled prenatal visit. She reports a recent onset of generalized fatigue and states she frequently needs to catch her breath after walking up a single flight of stairs to her apartment. The patient also notes intermittent "fluttering" sensations in her chest that last for a few seconds and resolve spontaneously. She denies any chest pain, fainting episodes, nighttime coughing, or orthopnea. Routine $28$-week laboratory tests, including a complete blood count and a $1$-hour oral glucose challenge test, performed last week were within normal limits. Her temperature is $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure is $102/62$ mm Hg, pulse is $96$/min, and respirations are $18$/min. On physical examination, the apical impulse is palpated in the fourth intercostal space, slightly lateral to the midclavicular line. Auscultation of the heart reveals a grade $2/6$ systolic ejection murmur at the left upper sternal border and a distinct third heart sound ($S_3$). The lungs are clear to auscultation bilaterally. Trace bilateral pitting pedal edema is noted. An in-office electrocardiogram demonstrates normal sinus rhythm with a leftward shift of the QRS axis compared to her first-trimester baseline, with no ST-segment or T-wave abnormalities. Which of the following is the most appropriate next step in the management of this patient?

An obstetric patient in her second pregnancy is admitted to the labor and delivery unit at 39 weeks and 4 days of gestation. Her previous pregnancy resulted in an uncomplicated vaginal delivery at term. She has a history of diet-controlled gestational diabetes mellitus. Currently, she reports painful uterine contractions that began four hours ago. She has not requested or received any systemic analgesia or regional anesthesia. Maternal temperature is 37.1°C (98.8°F), blood pressure is 118/76 mmHg, and pulse is 82/min. A sterile cervical examination reveals 5 cm dilation, 90% effacement, and the fetal vertex is at -1 station. Continuous electronic fetal monitoring is applied. Over the subsequent 50 minutes, the fetal heart rate tracing demonstrates a stable baseline of 145/min, continuous minimal variability (amplitude range of 3 to 4 beats/min), and a complete absence of both accelerations and decelerations. Uterine contractions are occurring every 4 minutes with a normal resting tone. Based on these clinical findings, which of the following is the most appropriate next step in management?

A 27-year-old woman, gravida 1, para 0, contacts the obstetrics clinic after a positive home pregnancy test. She is scheduled for a comprehensive prenatal care program. Her physician outlines the expected timeline of routine diagnostic tests and evaluations for an uncomplicated pregnancy. Arrange the following standard prenatal screenings and evaluations in the correct chronological order from earliest to latest gestational age.