04-09-2016, 02:33 AM
17. A 42-year-old woman, gravida 5, para 5, comes to the physician requesting advice regarding contraception. Menses occur at regular 28-day intervals. Her last menstrual period was 3 days ago. She has hypertension treated with a β-adrenergic blocking agent, but she often forgets to take it. At the age of 21 years, she was treated for Chlamydia trachomatis infection. During her second pregnancy, a Pap smear was reported as a low-grade squamous intraepithelial lesion; after delivery, a follow-up Pap smear showed no abnormalities. Since that time, she has had no abnormal Pap smears. She is sexually active and monogamous with her husband. Physical examination, including pelvic examination, shows no abnormalities. She desires the most effective contraception that she will easily remember to use. Which of the following is the most appropriate recommendation regarding contraception for this patient?
Condoms
Oral contraceptive
Diaphragm
Depot medroxyprogesterone
Placement of an IUD
18. A 36-year-old woman, gravida 2, para 1, at 41 weeks' gestation has had ruptured membranes without contractions for 8 hours. Her first infant weighed 4422 g (9 lb 12 oz) at birth. This pregnancy has been uncomplicated except for gestational diabetes, which was diagnosed at 26 weeks' gestation and has been well controlled with diet. Initial assessment shows a fundal height of 40 cm. On ultrasonography, the estimated fetal weight is 3714 g (8 lb 3 oz). The cervix is 2 cm dilated and 50% effaced. The fetal heart rate is within normal limits. Labor is induced with intravenous oxytocin. Four hours later, her cervix is 4 cm dilated and completely effaced. Continuous epidural anesthesia is administered. Two hours later, the fetal heart rate pattern demonstrates late decelerations with each contraction. The contractions occur every minute, last 45 seconds, and are 75 mm Hg at their peak. Which of the following is the most likely explanation for this pattern?
Epidural anesthesia
Fetal macrosomia
Gestational diabetes
Oxytocin administration
Postdates pregnancy
19. A 17-year-old primigravid patient comes to the physician because she has had decreased fetal movement over the past 2 days. She does not recall the date of her last menstrual period and has had only one previous prenatal visit. Examination shows a uterus consistent in size with a 32-week gestation. Ultrasonography shows a biparietal diameter consistent with a 31-week gestation. There is a duodenal bubble and flaccid tone of the fetus. Which of the following is the most likely cause of these findings?
Congenital megacolon (Hirschsprung disease)
Down syndrome
Fetal growth restriction
Gonadal dysgenesis 45,X (Turner syndrome)
Placental insufficiency
20. Three months after an uncomplicated vaginal delivery of a newborn at term, a 24-year-old woman, gravida 2, para 2, comes to the physician because of a 1-month history of pain with sexual intercourse. She breast-feeds her infant, who recently was treated for thrush. She awakens to feed him every 3 hours during the night. Her menses have not resumed. Vital signs are within normal limits. Physical examination shows no abnormalities. Pelvic examination shows an erythematous vagina with no discharge. The cervix is closed, and the uterus is normal in size. Which of the following is the most appropriate next step in management?
Recommendation for use of a lubricant
Pap smear
Vaginal culture
Antibiotic therapy
Antifungal therapy
21. An 18-year-old primigravid woman at 39 weeks' gestation delivers a newborn 2 days after developing chickenpox. The pregnancy had been otherwise uncomplicated. Which of the following is the most appropriate care for the newborn?
Observation for signs of infection
Acyclovir therapy
Immune globulin therapy
Interferon therapy
Varicella-zoster immune globulin therapy
22. A 20-year-old woman comes to the physician because of a 1-week history of vaginal discharge. She is sexually active with one partner, and they use condoms inconsistently. She reports that he was recently treated for syphilis. Physical examination of the patient shows no abnormalities. Pelvic examination shows white verrucous lesions over the upper vaginal wall and cervix. A Pap smear is reported as atypical squamous cells. Human papillomavirus testing is negative for high-risk types. Which of the following is the most likely diagnosis?
Bacterial vaginosis
Cervical intraepithelial neoplasia (CIN) 2
Condylomata acuminata
Herpes simplex
Secondary syphilis
23. A 27-year-old woman, gravida 2, para 1, aborta 1, comes to the physician because of a 3-day history of increasing abdominal pain and a 1-day history of fever. Five days ago, she underwent an uncomplicated abortion at 10 weeks' gestation and received prophylactic antibiotics. Her temperature is 39.2°C (102.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 90/50 mm Hg. Physical examination shows a tender uterus consistent in size with a 12-week gestation and no adnexal masses. Pelvic ultrasonography shows a heterogeneous endometrial mass. After intravenous antibiotic therapy is started, she undergoes suction dilatation and curettage followed by sharp curettage to remove the infected material. This patient is at increased risk for which of the following conditions?
Amenorrhea
Endometrial cancer
Leiomyomata uteri
Ovarian cancer
Polycystic ovarian syndrome
Premature ovarian failure
24. Two days after a cesarean delivery for fetal distress, a 27-year-old woman has temperatures to 38.2°C (100.8°F). She had an 8-hour labor complicated by mild meconium-stained amniotic fluid. Membranes ruptured 2 hours after admission. Breath sounds are decreased at both lung bases. Abdominal examination shows mild tenderness below the umbilicus and a well-healing incision. There is a moderate amount of lochia with no odor. Examination of the lower extremities shows edema and no tenderness. Her hemoglobin concentration is 10.8 g/dL, leukocyte count is 14,000/mm3, and platelet count is 189,000/mm3. A urine catheter specimen is negative. Which of the following is the most likely diagnosis?
Atelectasis
Deep venous thrombosis
Endometritis
Episiotomy infection
Mastitis
Pneumonia
Pulmonary embolism
Pyelonephritis
Septic pelvic thrombophlebitis
Ureteral obstruction
Urinary tract infection
25 A 15-year-old girl is brought to the physician because of a 3-day history of fever, abdominal pain, and nausea. She also has had a thick, white vaginal discharge. Menarche was at the age of 13 years, and her menses occur at irregular 28- to 40-day intervals. She became sexually active 1 month ago and uses condoms inconsistently. Her temperature is 39.6°C (103.2°F), pulse is 108/min, respirations are 20/min, and blood pressure is 102/80 mm Hg. Examination shows lower abdominal tenderness. Pelvic examination shows pain with cervical motion and adnexal tenderness with a 3-cm mass. A Gram stain of vaginal discharge shows gram-negative diplococci. Which of the following is the most likely explanation for this patient's susceptibility to this condition?
Immature immune system
Increased cervical cell vulnerability to infections
Increased concentrations of progesterone
Latex hypersensitivity
Menarche before 14 years of age
26. A 19-year-old woman comes to the emergency department because of moderate lower abdominal pain and vaginal spotting that began after her last menstrual period 2 weeks ago. Menses occur at regular 28-day intervals. She underwent a first trimester elective abortion 8 months ago and has been using an oral contraceptive since then. She has been sexually active with one male partner for 1 year. Her temperature is 37.6°C (99.6°F); other vital signs are within normal limits. Abdominal examination shows no tenderness. Pelvic examination shows blood-tinged discharge at the cervical os. There is cervical motion and mild uterine tenderness. A urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?
Chlamydia trachomatis infection
Endometrial polyp
Levonorgestrel-induced endometrial atrophy
Retained products of conception
Trichomoniasis
27 A widowed 37-year-old woman, gravida 3, para 3, whose youngest child is 10 years old, has had increasingly heavy but regular menstrual periods for the past 3 years. Her last menses occurred 2½ weeks ago. She reports a 2-day history of labor-like pains accompanied by a small amount of vaginal bleeding. Speculum examination shows that the cervix is moderately effaced and 2 cm dilated, with some beefy red tissue at the os. Which of the following is the most likely diagnosis?
Carcinoma of the cervix
Carcinoma of the endometrium
Incomplete abortion
Pedunculated submucous leiomyoma uteri
Sarcoma of the uterus
28 A 22-year-old woman comes to the physician because of a 2-week history of increasingly severe vaginal burning and discharge. She has been sexually active with one partner for 1 year, and they use condoms consistently for contraception. Examination shows normal external genitalia and a gray frothy vaginal discharge. The pH of the vaginal discharge is 5; microscopic examination shows squamous epithelial cells coated with bacteria. Which of the following is the most appropriate pharmacotherapy?
Hydrogen peroxide douches
Oral azithromycin
Vaginal estrogen
Vaginal metronidazole gel
Vaginal miconazole
29 A 37-year-old primigravid woman at 35 weeks' gestation comes to the physician for a routine prenatal visit. She has been receiving routine prenatal care since 8 weeks' gestation. Pregnancy has been complicated by the onset of hypertension at 18 weeks' gestation that has been well controlled with labetalol. She has an 18-year history of type 1 diabetes mellitus. Her hemoglobin A1c at 8 weeks' gestation was 5.7%. Her blood pressure now is 140/90 mm Hg. Examination shows a soft uterus with a fundal height of 32 cm. The fetal heart rate is 140/min. Serum studies show a urea nitrogen concentration of 8 mg/dL and creatinine concentration of 1 mg/dL. A 24-hour urine collection shows a protein concentration of 800 mg. Ultrasonography shows a normal fetus at the 5th percentile for weight; the placenta is anterior and fundal. There is a mild decrease in the amount of amniotic fluid. Which of the following is the most likely cause of the ultrasound findings?
Adverse drug effect
Fetal congenital malformation
Incorrect gestational age
Placental dysfunction
Trisomy 21
30 A 27-year-old woman who is a long-distance runner comes to the physician because of a 1-month history of postcoital spotting lasting 1 to 2 days. Menses have occurred at regular intervals since menarche at the age of 14 years. She underwent a bilateral tubal ligation 9 months ago. She is sexually active with a new partner. Which of the following is the most likely diagnosis?
Blood dyscrasia
Broad-ligament leiomyomata uteri
Cervicitis
Exercise-related menstrual irregularity
Ovarian cancer
Polycystic ovarian syndrome
Pregnancy
Premature ovarian failure
Condoms
Oral contraceptive
Diaphragm
Depot medroxyprogesterone
Placement of an IUD
18. A 36-year-old woman, gravida 2, para 1, at 41 weeks' gestation has had ruptured membranes without contractions for 8 hours. Her first infant weighed 4422 g (9 lb 12 oz) at birth. This pregnancy has been uncomplicated except for gestational diabetes, which was diagnosed at 26 weeks' gestation and has been well controlled with diet. Initial assessment shows a fundal height of 40 cm. On ultrasonography, the estimated fetal weight is 3714 g (8 lb 3 oz). The cervix is 2 cm dilated and 50% effaced. The fetal heart rate is within normal limits. Labor is induced with intravenous oxytocin. Four hours later, her cervix is 4 cm dilated and completely effaced. Continuous epidural anesthesia is administered. Two hours later, the fetal heart rate pattern demonstrates late decelerations with each contraction. The contractions occur every minute, last 45 seconds, and are 75 mm Hg at their peak. Which of the following is the most likely explanation for this pattern?
Epidural anesthesia
Fetal macrosomia
Gestational diabetes
Oxytocin administration
Postdates pregnancy
19. A 17-year-old primigravid patient comes to the physician because she has had decreased fetal movement over the past 2 days. She does not recall the date of her last menstrual period and has had only one previous prenatal visit. Examination shows a uterus consistent in size with a 32-week gestation. Ultrasonography shows a biparietal diameter consistent with a 31-week gestation. There is a duodenal bubble and flaccid tone of the fetus. Which of the following is the most likely cause of these findings?
Congenital megacolon (Hirschsprung disease)
Down syndrome
Fetal growth restriction
Gonadal dysgenesis 45,X (Turner syndrome)
Placental insufficiency
20. Three months after an uncomplicated vaginal delivery of a newborn at term, a 24-year-old woman, gravida 2, para 2, comes to the physician because of a 1-month history of pain with sexual intercourse. She breast-feeds her infant, who recently was treated for thrush. She awakens to feed him every 3 hours during the night. Her menses have not resumed. Vital signs are within normal limits. Physical examination shows no abnormalities. Pelvic examination shows an erythematous vagina with no discharge. The cervix is closed, and the uterus is normal in size. Which of the following is the most appropriate next step in management?
Recommendation for use of a lubricant
Pap smear
Vaginal culture
Antibiotic therapy
Antifungal therapy
21. An 18-year-old primigravid woman at 39 weeks' gestation delivers a newborn 2 days after developing chickenpox. The pregnancy had been otherwise uncomplicated. Which of the following is the most appropriate care for the newborn?
Observation for signs of infection
Acyclovir therapy
Immune globulin therapy
Interferon therapy
Varicella-zoster immune globulin therapy
22. A 20-year-old woman comes to the physician because of a 1-week history of vaginal discharge. She is sexually active with one partner, and they use condoms inconsistently. She reports that he was recently treated for syphilis. Physical examination of the patient shows no abnormalities. Pelvic examination shows white verrucous lesions over the upper vaginal wall and cervix. A Pap smear is reported as atypical squamous cells. Human papillomavirus testing is negative for high-risk types. Which of the following is the most likely diagnosis?
Bacterial vaginosis
Cervical intraepithelial neoplasia (CIN) 2
Condylomata acuminata
Herpes simplex
Secondary syphilis
23. A 27-year-old woman, gravida 2, para 1, aborta 1, comes to the physician because of a 3-day history of increasing abdominal pain and a 1-day history of fever. Five days ago, she underwent an uncomplicated abortion at 10 weeks' gestation and received prophylactic antibiotics. Her temperature is 39.2°C (102.6°F), pulse is 110/min, respirations are 24/min, and blood pressure is 90/50 mm Hg. Physical examination shows a tender uterus consistent in size with a 12-week gestation and no adnexal masses. Pelvic ultrasonography shows a heterogeneous endometrial mass. After intravenous antibiotic therapy is started, she undergoes suction dilatation and curettage followed by sharp curettage to remove the infected material. This patient is at increased risk for which of the following conditions?
Amenorrhea
Endometrial cancer
Leiomyomata uteri
Ovarian cancer
Polycystic ovarian syndrome
Premature ovarian failure
24. Two days after a cesarean delivery for fetal distress, a 27-year-old woman has temperatures to 38.2°C (100.8°F). She had an 8-hour labor complicated by mild meconium-stained amniotic fluid. Membranes ruptured 2 hours after admission. Breath sounds are decreased at both lung bases. Abdominal examination shows mild tenderness below the umbilicus and a well-healing incision. There is a moderate amount of lochia with no odor. Examination of the lower extremities shows edema and no tenderness. Her hemoglobin concentration is 10.8 g/dL, leukocyte count is 14,000/mm3, and platelet count is 189,000/mm3. A urine catheter specimen is negative. Which of the following is the most likely diagnosis?
Atelectasis
Deep venous thrombosis
Endometritis
Episiotomy infection
Mastitis
Pneumonia
Pulmonary embolism
Pyelonephritis
Septic pelvic thrombophlebitis
Ureteral obstruction
Urinary tract infection
25 A 15-year-old girl is brought to the physician because of a 3-day history of fever, abdominal pain, and nausea. She also has had a thick, white vaginal discharge. Menarche was at the age of 13 years, and her menses occur at irregular 28- to 40-day intervals. She became sexually active 1 month ago and uses condoms inconsistently. Her temperature is 39.6°C (103.2°F), pulse is 108/min, respirations are 20/min, and blood pressure is 102/80 mm Hg. Examination shows lower abdominal tenderness. Pelvic examination shows pain with cervical motion and adnexal tenderness with a 3-cm mass. A Gram stain of vaginal discharge shows gram-negative diplococci. Which of the following is the most likely explanation for this patient's susceptibility to this condition?
Immature immune system
Increased cervical cell vulnerability to infections
Increased concentrations of progesterone
Latex hypersensitivity
Menarche before 14 years of age
26. A 19-year-old woman comes to the emergency department because of moderate lower abdominal pain and vaginal spotting that began after her last menstrual period 2 weeks ago. Menses occur at regular 28-day intervals. She underwent a first trimester elective abortion 8 months ago and has been using an oral contraceptive since then. She has been sexually active with one male partner for 1 year. Her temperature is 37.6°C (99.6°F); other vital signs are within normal limits. Abdominal examination shows no tenderness. Pelvic examination shows blood-tinged discharge at the cervical os. There is cervical motion and mild uterine tenderness. A urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?
Chlamydia trachomatis infection
Endometrial polyp
Levonorgestrel-induced endometrial atrophy
Retained products of conception
Trichomoniasis
27 A widowed 37-year-old woman, gravida 3, para 3, whose youngest child is 10 years old, has had increasingly heavy but regular menstrual periods for the past 3 years. Her last menses occurred 2½ weeks ago. She reports a 2-day history of labor-like pains accompanied by a small amount of vaginal bleeding. Speculum examination shows that the cervix is moderately effaced and 2 cm dilated, with some beefy red tissue at the os. Which of the following is the most likely diagnosis?
Carcinoma of the cervix
Carcinoma of the endometrium
Incomplete abortion
Pedunculated submucous leiomyoma uteri
Sarcoma of the uterus
28 A 22-year-old woman comes to the physician because of a 2-week history of increasingly severe vaginal burning and discharge. She has been sexually active with one partner for 1 year, and they use condoms consistently for contraception. Examination shows normal external genitalia and a gray frothy vaginal discharge. The pH of the vaginal discharge is 5; microscopic examination shows squamous epithelial cells coated with bacteria. Which of the following is the most appropriate pharmacotherapy?
Hydrogen peroxide douches
Oral azithromycin
Vaginal estrogen
Vaginal metronidazole gel
Vaginal miconazole
29 A 37-year-old primigravid woman at 35 weeks' gestation comes to the physician for a routine prenatal visit. She has been receiving routine prenatal care since 8 weeks' gestation. Pregnancy has been complicated by the onset of hypertension at 18 weeks' gestation that has been well controlled with labetalol. She has an 18-year history of type 1 diabetes mellitus. Her hemoglobin A1c at 8 weeks' gestation was 5.7%. Her blood pressure now is 140/90 mm Hg. Examination shows a soft uterus with a fundal height of 32 cm. The fetal heart rate is 140/min. Serum studies show a urea nitrogen concentration of 8 mg/dL and creatinine concentration of 1 mg/dL. A 24-hour urine collection shows a protein concentration of 800 mg. Ultrasonography shows a normal fetus at the 5th percentile for weight; the placenta is anterior and fundal. There is a mild decrease in the amount of amniotic fluid. Which of the following is the most likely cause of the ultrasound findings?
Adverse drug effect
Fetal congenital malformation
Incorrect gestational age
Placental dysfunction
Trisomy 21
30 A 27-year-old woman who is a long-distance runner comes to the physician because of a 1-month history of postcoital spotting lasting 1 to 2 days. Menses have occurred at regular intervals since menarche at the age of 14 years. She underwent a bilateral tubal ligation 9 months ago. She is sexually active with a new partner. Which of the following is the most likely diagnosis?
Blood dyscrasia
Broad-ligament leiomyomata uteri
Cervicitis
Exercise-related menstrual irregularity
Ovarian cancer
Polycystic ovarian syndrome
Pregnancy
Premature ovarian failure