All practice questions

A 30-year-old nulliparous woman at 40 weeks and 1 day of gestation is managed on the labor unit. She was admitted 8 hours ago in spontaneous active labor. Four hours ago, her cervical examination revealed 6 cm dilation, 100% effacement, and 0 station. Spontaneous rupture of membranes occurred around that time, and the amniotic fluid was clear. An intrauterine pressure catheter was subsequently placed. Over the last four hours, she has consistently had 4 to 5 uterine contractions every 10 minutes, generating a total of 240 to 260 Montevideo units. Re-evaluation of her cervix just now shows no change from the prior examination. The maternal vital signs are within normal limits. The fetal heart rate tracing exhibits a baseline of 140/min, moderate baseline variability, the presence of accelerations, and no decelerations. Which of the following is the most appropriate next step in management?

A 22-year-old female is evaluated in the emergency department for three days of worsening right-sided abdominal pain and lower pelvic discomfort. The abdominal pain is sharp, exacerbated by deep inspiration, and accompanied by nausea. She has a past medical history of asthma and a severe allergic reaction to amoxicillin during childhood that resulted in anaphylaxis and endotracheal intubation. Her temperature is 38.9°C (102.0°F), blood pressure is 112/72 mmHg, and pulse is 114/min. Physical examination reveals right upper quadrant tenderness with a palpable friction rub over the anterior costal margin, as well as profound bilateral lower abdominal tenderness. Pelvic examination demonstrates a friable cervix with mucopurulent discharge at the cervical os and exquisite pain on cervical motion. Laboratory studies show a leukocyte count of 16,800/mm³. Liver aminotransferases and alkaline phosphatase levels are within normal limits. A right upper quadrant ultrasound demonstrates no biliary abnormalities and no pericholecystic fluid. Which of the following is the most appropriate initial pharmacologic management for this patient?

A 32-year-old woman, gravida 2, para 2, experiences sudden, massive vaginal bleeding shortly after a spontaneous vaginal delivery at 39 weeks gestation. The placenta delivered spontaneously 5 minutes ago with gentle cord traction. Her blood pressure is 78/40 mmHg and her pulse is 135/min. On physical examination, the uterine fundus cannot be palpated in the abdomen. Pelvic examination reveals a red, fleshy, globular mass protruding through the external cervical os. Arrange the following management steps in the correct sequential order for this patient's condition.

A 64-year-old female presents to the gynecology clinic evaluating intermittent vaginal bleeding that has been ongoing for the past two months. She notes that the bleeding is particularly noticeable after intercourse. She reached menopause at age 52 and takes no medications. Her last gynecologic examination and cervical cancer screening were over two decades ago. Vital signs are within normal limits. Speculum examination reveals a 3.5-cm friable, ulcerated mass on the anterior lip of the cervix that bleeds on contact. Bimanual examination demonstrates a normal-sized, mobile uterus with no adnexal masses. A transvaginal ultrasound shows an endometrial stripe of 2.5 mm. Which of the following is the most appropriate next step in the management of this patient?

An otherwise healthy couple arrives at the reproductive endocrinology clinic for their first consultation regarding primary infertility. They have been actively attempting to conceive for 18 months without success. The female partner is 27 years old, reports predictable 28-day menstrual cycles, and denies any history of pelvic pain, abdominal surgeries, or sexually transmitted infections. The male partner is 29 years old and has no significant past medical history. They are eager to understand the step-by-step process of their care. Arrange the following steps of their evaluation and management in the most appropriate standard chronological sequence, starting from the initial diagnostic step and concluding with the most advanced therapeutic intervention.

Match each obstetric clinical scenario to the most appropriate targeted pharmacologic intervention, taking into account the specific indications and contraindications for each patient.

An established $37$-year-old patient visits the outpatient clinic requesting a new birth control strategy. Over the last $9$ months, she has experienced increasingly heavy menstrual bleeding, often soaking through her clothes and requiring her to take days off work. She previously relied on condoms but desires a highly effective, long-acting method. Her medical background is significant for recurrent right-sided headaches that are preceded by visual bright spots, for which she occasionally takes sumatriptan. She currently consumes one pack of cigarettes per day. Vital signs include a blood pressure of $122/78$ mm Hg, a heart rate of $76$/min, and a body mass index (BMI) of $23$ kg/m $^2$. General physical and pelvic examinations are unremarkable. A urine human chorionic gonadotropin test is negative.

Laboratory studies reveal:
Hemoglobin: $10.5$ g/dL
Thyroid-stimulating hormone: $2.1$ mIU/L
Prolactin: $14$ ng/mL

The patient firmly declines any permanent surgical interventions. Which of the following is the most appropriate next step in the management of this patient?

A 19-year-old collegiate gymnast comes to the clinic for evaluation of absent menstrual periods for the past 10 months. Menarche occurred at age 13, and her menses were previously regular, occurring every 28 to 30 days. She trains approximately 25 hours per week and follows a strict, calorie-restricted diet to maintain her competition weight. Four weeks ago, she sustained a tibial stress fracture. She does not use tobacco, alcohol, or illicit drugs. She is not sexually active. Vital signs show a blood pressure of 94/60 mm Hg and a heart rate of 52/min. Her BMI is $17.8 \text{ kg/m}^2$. Physical examination is unremarkable except for fine, downy hair over her face and arms. Pelvic examination reveals normal female external genitalia and a normal appearing cervix.

Laboratory studies show:

A dual-energy x-ray absorptiometry (DEXA) scan reveals a Z-score of $-2.2$ at the lumbar spine. The patient is anxious about her bone health and requests a prescription to "fix her hormones." She states she must maintain her current training intensity for an upcoming championship. Which of the following is the most appropriate next step in the management of this patient?

Match each classic clinical finding in a patient with primary postpartum hemorrhage to its most likely underlying etiology.

A 25-year-old woman is evaluated in the emergency department for severe bilateral lower quadrant abdominal pain, intractable nausea, and a fever of $39.1^{\circ}\text{C}$ ($102.4^{\circ}\text{F}$). She is unable to tolerate oral fluids. On pelvic examination, there is severe cervical motion tenderness and a palpable left adnexal fullness. Arrange the following steps in the correct chronological sequence for the standard diagnostic workup and management escalation of this patient's suspected complicated Pelvic Inflammatory Disease (PID).

Following a spontaneous vaginal delivery of a $4150\text{ g}$ neonate, a $28$-year-old multiparous patient develops sudden, massive vaginal hemorrhage. The delivery was complicated by a prolonged second stage. During the third stage of labor, strong umbilical cord traction was applied prior to spontaneous placental separation. The patient now reports severe, agonizing lower abdominal pain and severe lightheadedness. Vital signs show a blood pressure of $76/40\text{ mmHg}$ and a heart rate of $142/\text{min}$. Pelvic examination reveals a firm, smooth, beefy-red mass completely filling the vaginal vault, with the placenta still densely attached to its surface. Abdominal palpation fails to identify a uterine fundus in the pelvis. An initial bedside attempt by the physician to manually push the mass cephalad is thwarted by a tightly contracted lower cervical ring. Massive transfusion protocol is activated. Arrange the following subsequent critical management steps in the correct chronological order.

A 25-year-old woman presents to the ambulatory care clinic with complaints of increased, yellowish vaginal discharge for the past week. She denies any pelvic pain, fever, nausea, or burning with urination. The patient is sexually active with a new male partner and reports inconsistent use of barrier contraception. Her medical history is unremarkable, and she takes only a daily oral contraceptive pill. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and a heart rate of 78/min. On pelvic examination, the vagina appears normal, but the cervix is erythematous, edematous, and bleeds easily upon speculum contact. A sample of mucopurulent discharge is visible at the cervical os. Bimanual examination demonstrates a normal-sized, non-tender uterus and no adnexal masses or cervical motion tenderness. A rapid nucleic acid amplification test (NAAT) performed in the clinic on a cervical swab returns positive for *Neisseria gonorrhoeae* and negative for *Chlamydia trachomatis*.

Which of the following is the most appropriate pharmacotherapy for this patient?

A 25-year-old primigravida at 38 weeks gestation is evaluated in the labor and delivery unit for active labor. Her pregnancy has been uncomplicated. Her temperature is 37.0°C (98.6°F), blood pressure is 118/76 mm Hg, and pulse is 82/min. Cervical examination reveals 5 cm dilation, 100% effacement, and 0 station. Artificial rupture of membranes was performed 1 hour ago, yielding clear amniotic fluid. Uterine contractions are occurring every 3 to 4 minutes and palpate as strong. External fetal monitoring shows a baseline heart rate of 140/min with moderate variability. Over the last 30 minutes, there are abrupt decreases in the fetal heart rate to 85/min that last for 40 to 50 seconds before rapidly returning to baseline. These decreases occur in association with 60% of the uterine contractions, and their timing varies relative to the peak of the contractions. The patient is currently positioned in the left lateral decubitus position and is receiving a bolus of intravenous lactated Ringer solution, but the fetal heart rate pattern remains unchanged. Which of the following is the most appropriate next step in management?

A 34-year-old woman comes to the office for evaluation of secondary amenorrhea. Her last menstrual period was 14 months ago. At that time, she underwent a dilation and curettage for an incomplete abortion, which was complicated by postpartum endometritis requiring intravenous antibiotics. Prior to this pregnancy, her menstrual cycles were regular every 28 days. She reports no hot flashes, galactorrhea, weight changes, or visual disturbances. Her body mass index is 23 kg/m². Physical examination reveals normal secondary sexual characteristics and no evidence of hirsutism or acne. A urine pregnancy test is negative. Serum laboratory testing shows normal levels of follicle-stimulating hormone, luteinizing hormone, prolactin, and thyroid-stimulating hormone. A 10-day course of oral medroxyprogesterone acetate is administered, but no withdrawal bleeding occurs. Subsequently, she is given a 21-day course of oral estrogen followed by 7 days of progestin, which also fails to induce withdrawal bleeding. Which of the following is the most likely diagnosis?

A 6-month-old boy is brought to the pediatric clinic by his parents for a routine well-child visit. His parents express significant concern because the infant is not yet crawling and cannot pick up small objects with his thumb and index finger. He is currently able to roll in both directions, sit momentarily without support, and babble. Over the past three weeks, the parents have noted that he is increasingly irritable and has had multiple episodes of forceful vomiting, primarily occurring in the morning. He has no history of fever, trauma, or diarrhea.

Vital signs are temperature 37.1°C (98.8°F), heart rate 110/min, and respiratory rate 24/min. Weight is at the 50th percentile, and length is at the 45th percentile. Head circumference has increased from the 60th percentile at age 4 months to the 98th percentile currently. On physical examination, the anterior fontanelle is full and tense. Neurologic examination reveals downward deviation of the eyes with sclera visible above the iris. The remainder of the examination is unremarkable.

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

A first-time mother brings her $4$-week-old boy to the acute care clinic because he has been forcefully vomiting after every meal for the last $48$ hours. The vomit does not contain bile. She notes that he appears extremely hungry and eagerly attempts to feed again immediately after these episodes. Vital signs reveal a heart rate of $162 \text{ beats/min}$ and a respiratory rate of $32 \text{ breaths/min}$. On physical examination, the infant has dry mucous membranes, a sunken anterior fontanelle, and delayed capillary refill. Careful abdominal palpation reveals a firm, olive-shaped mass in the right upper quadrant.

Laboratory analysis demonstrates:

Which of the following represents the most appropriate initial step in the care of this patient?

A 32-year-old woman comes to the office due to the absence of menstrual periods for the past 9 months. Her menarche occurred at age 13, and her menses were previously regular, occurring every 28 days and lasting 5 days. Over the last year, she has experienced progressive fatigue, cold intolerance, and a 5-kg (11-lb) weight gain despite a decreased appetite. She has no headaches, visual disturbances, or galactorrhea. Her medical history is unremarkable, and she takes no medications. Vital signs show a blood pressure of 102/64 mmHg and a pulse of 54/min. Physical examination reveals dry, cool skin and a delayed relaxation phase of the deep tendon reflexes. Pelvic examination is normal with no clitoromegaly. A urine pregnancy test is negative.

Laboratory evaluation shows:
Thyroid-stimulating hormone (TSH): 1.3 mIU/L (Normal: 0.5–5.0 mIU/L)
Free thyroxine (T4): 0.4 ng/dL (Normal: 0.8–1.8 ng/dL)
Prolactin: 12 ng/mL (Normal: < 25 ng/mL)
Follicle-stimulating hormone (FSH): 3 mIU/mL (Normal: 5–20 mIU/mL)
Luteinizing hormone (LH): 2 mIU/mL (Normal: 5–20 mIU/mL)

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

An obstetrical care team is evaluating a patient at 39 weeks gestation who is undergoing an induction of labor for gestational diabetes mellitus. She is currently receiving a continuous intravenous oxytocin infusion. Ten minutes ago, she reported a sudden onset of mild shortness of breath. Her vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $122/78\text{ mm Hg}$, heart rate $95\text{/min}$, and respiratory rate $20\text{/min}$. Oxygen saturation is $98\%$ on room air. An arterial blood gas analysis reveals:

* $\text{pH}$: $7.44$
* $\text{PaCO}_2$: $29\text{ mm Hg}$
* $\text{PaO}_2$: $104\text{ mm Hg}$

The electronic fetal monitor demonstrates a baseline heart rate of $145\text{/min}$ with moderate variability. In the past 20 minutes, there have been five uterine contractions. Following three of these contractions, the fetal heart rate gradually decreased to a nadir of $125\text{/min}$, with the nadir occurring after the peak of the contraction, before returning to the baseline. The cervix is 5 cm dilated and 80% effaced. Which of the following is the most appropriate next step in management?

Match each clinical presentation of a gynecologic infection with the most appropriate, guideline-concordant next step in management.

Match each severe intrapartum or puerperal complication to its most classic clinical presentation and associated risk factors.