DIRECTIONS: Each item contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.
216. A baby is born with ambiguous genitalia. Which of the following statements is true?
a. A karyotype is rarely needed b. Evaluation should be done by 1 month of age c. It is sometimes associated with a history of a previous sibling with congenital adrenal hyperplasia (CAH)
d. A thorough physical examination can usually decide the true sex e. Laparotomy or laparoscopy is required for all CAH cases
A 24-year-old primigravid woman, who is intent on breast-feeding, decides on a home delivery. Immediately after the birth of a 4.1-kg (9-lb) infant, the patient bleeds massively from extensive vaginal and cervical lacerations. She is brought to the nearest hospital in shock. Over 2 h, 9 units of blood are transfused, and the patient's blood pressure returns to a reasonable level. A hemoglobin value the next day is 7.5 g/dL, and 3 units of packed red blood cells are given.
217. The most likely late sequela to consider in this woman would be a. Hemochromatosis b. Stein-Leventhal syndrome c. Sheehan syndrome d. Simmonds syndrome e. Cushing syndrome
218. Development of the sequela could be evident as early as a. 6 h postpartum b. 1 week postpartum c. 1 month postpartum d. 6 month postpartum e. 1 year postpartum
219. Puerperal fever from breast engorgement a. Appears in less than 5% of postpartum women b. Appears 3 to 4 days after the development of lacteal secretion c. Is almost painless d. Rarely exceeds 37.8°C (99.8°F)
e. Is less severe and less common if lactation is suppressed
220. In the mother, suckling leads to which of the following responses?
a. Decrease of oxytocin b. Increase of prolactin-inhibiting factor c. Increase of hypothalamic dopamine d. Increase of hypothalamic prolactin e. Increase of luteinizing hormone-releasing factor
221. Which of the following statements regarding the postpartum development of pulmonary embolism (PE) is true?
a. It is a relatively uncommon phenomenon, with an incidence of about 1 in 5000
b. In most cases, the classic triad of hemoptysis, pleuritic chest pain, and dyspnea suggests the diagnosis c. A mismatch in ventilation-perfusion scan is pathognomonic of PE
d. The most common finding at physical examination is a pleuritic friction rub
222. Septic pelvic thrombophlebitis may be characterized by which of the following statements?
a. It usually involves both the iliofemoral and ovarian veins b. Antimicrobial therapy is usually ineffective c. Fever spikes are rare d. It is usually associated with fever without pain or palpable masses e. Vena caval thrombosis may accompany either ovarian or iliofemoral thrombophlebitis
223. True statements regarding postpartum depression include which of the following?
a. A history of depression is not a risk factor for developing postpartum depression b. Prenatal preventive intervention for patients at high risk for postpartum depression is best managed alone by a mental health professional c. Young, multiparous patients are at highest risk d. Postpartum depression is a self-limiting process that lasts for a maximum of 3 months e. About 10 to 12% of women develop postpartum depression
224. A postpartum woman has acute puerperal mastitis. Which of the following statements is true?
a. The initial treatment is penicillin b. The source of the infection is usually the infant's gastrointestinal (GI) tract c. Frank abscesses may develop and require drainage d. The most common offending organism is Escherichia coli e. The symptoms include lethargy
225. True statements concerning infants born to mothers with active tuberculosis include which of the following?
a. The risk of active disease during the first year of life may approach 90% without prophylaxis b. Bacille Calmette-Guérin (BCG) vaccination of the newborn infant without evidence of active disease is not appropriate c. Future ability for tuberculin skin testing is lost after BCG administration to the newborn d. Neonatal infection is most likely acquired by aspiration of infected amniotic fluid e. Congenital infection is common despite therapy
226. A 21-year-old has difficulty voiding 6 h postpartum. The least likely cause is which of the following?
a. Preeclampsia b. Infusion of oxytocin after delivery c. Vulvar hematoma d. Urethral trauma e. Use of general anesthesia
227. Breast-feeding can be encouraged despite which of the following conditions?
a. Maternal hepatitis B
b. Maternal reduction mammoplasty with transplantation of the nipples c. Maternal acute puerperal mastitis d. Maternal treatment with lithium carbonate e. Maternal treatment with tetracyclines
A woman develops endometritis after a cesarean section has been performed. She is treated with penicillin and gentamicin but fails to respond.
228. Which of the following bacteria is resistant to these antibiotics and is likely to be responsible for this woman's infection?
a. Proteus mirabilis b. Bacteroides fragilis c. Escherichia coli d. a streptococci e. Anaerobic streptococci
229. The treatment of choice for this woman's condition would be a. Polymyxin b. Ampicillin c. Cephalothin d. Vancomycin e. Clindamycin
230. A 23-year-old woman (gravida 2, para 2) calls her physician 7 days postpartum because she is concerned that she is still bleeding from the vagina. It would be appropriate to tell this woman that it is normal for bloody lochia to last up to a. 2 days b. 5 days c. 8 days d. 11 days e. 14 days
231. Which of the following potential treatments for use in the initial care of late postpartum hemorrhage would be contraindicated?
a. Methylergonovine maleate (Methergine)
b. Oxytocin injection (Pitocin)
c. Ergonovine maleate (Ergotrate)
d. Prostaglandins e. Dilation and curettage
232. A 22-year-old gravida 1, para 0 has just undergone a spontaneous vaginal delivery. As the placenta is being delivered, an inverted uterus prolapses out of the vagina. The maneuver most likely to exacerbate the situations would be to a. Immediately finish delivering the placenta by removing it from the inverted uterus b. Call for immediate assistance from other medical personnel c. Obtain intravenous access and give lactated Ringer solution d. Apply pressure to the fundus with the palm of the hand and fingers in the direction of the long axis of the vagina e. Have the anesthesiologist administer halothane anesthesia for uterine relaxation
233. Following a vaginal delivery, a woman develops a fever, lower abdominal pain, and uterine tenderness. She is alert, and her blood pressure and urine output are good. Large gram-positive rods suggestive of clostridia are seen in a smear of the cervix. Which of the following is most closely tied to a decision to proceed with hysterectomy?
a. Close observation for renal failure or hemolysis b. Immediate radiographic examination for hydrosalpinx c. High-dose antibiotic therapy d. Fever of 103°C
e. Gas gangrene
Three days ago you delivered a 40-year-old G1P1 by cesarean section. The indication for operative delivery was failure to descend after 2 h of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse pages you to come see the patient on the postpartum floor because she has a fever of 102°F and is experiencing shaking chills. Her BP is 120/70 and her pulse is 120. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breast-feed, but says her milk has not come in yet. On physical exam, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted.
234. What is the patient's most likely diagnosis?
a. Pelvic abscess b. Septic pelvic thrombophlebitis c. Wound infection d. Metritis e. Atelectasis
235. What is the most appropriate antibiotic to treat this patient with initially?
a. Oral Bactrim b. Oral dicloxacillin c. Oral ciprofloxacin d. Intravenous gentamicin e. Intravenous cefotetan
A 34-year-old patient who delivered her first baby 5 weeks ago calls your office and asks to speak with you. She tells you that she is feeling very overwhelmed and anxious. She feels that she cannot do anything right and feels sad throughout the day She tells you that she finds herself crying all the time and is unable to sleep at night.
236. What is the most likely diagnosis?
a. Postpartum depression b. Maternity blues c. Postpartum psychosis d. Bipolar disease e. Postpartum blues
237. What treatment do you recommend?
a. Time and reassurance, because this condition is self-limited b. Referral to psychiatry for counseling and antidepressant therapy c. Referral to psychiatry for admission to a psychiatry ward and therapy with Haldol d. A sleep aid e. Referral to a psychiatrist who can administer electroconvulsive therapy
A patient delivered a baby boy 2 days ago and is trying to decide whether or not to have you perform a circumcision on her newborn. The boy is in the well baby nursery and is doing very well. The patient had an uncomplicated vaginal delivery, and the baby weighed 6 lb, 10 oz.
238. In counseling this patient, you tell her which of the following recommendations from the American Pediatric Association?
a. Circumcisions should be performed routinely because they decrease the incidence of male urinary tract infections b. Circumcisions should be performed routinely because they decrease the incidence of penile cancer c. Circumcisions should be performed routinely because they decrease the incidence of sexually transmitted diseases d. Circumcisions should not be performed routinely because of insufficient data regarding risks and benefits e. Circumcisions should not be performed routinely because it is a risky procedure and complications such as bleeding and infection are common
239. The parents decide to go ahead with the procedure and ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?
a. Analgesia is not recommended because there is no evidence that newborns undergoing circumcision experience pain b. Analgesia is not recommended because it is unsafe in newborns c. Analgesia in the form of oral Tylenol is the pain medicine of choice recommended for circumcisions d. Analgesia in the form of a penile block is recommended e. The administration of sugar orally during the procedure will keep the neonate preoccupied and happy
240. A patient was induced for being postterm at 423/7 weeks. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical exam: a small amount of cartilage in the ear-lobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae. Based on this physical exam, what is the approximate gestational age of this male infant?
Your patient is a 40-year-old G4P5 who is 39 weeks and has progressed rapidly in labor with a reassuring fetal heart rate pattern. She has had an uncomplicated pregnancy with normal prenatal labs including an amniocentesis for advanced maternal age. The patient begins the second stage of labor and after 15 min of pushing starts to demonstrate deep variable heart rate accelerations. You suspect that she may have a fetus with a nuchal cord. You expediently deliver the baby by low outlet forceps and hand the baby over to the neonatologists called to attend the delivery. As soon as the baby is handed off to the pediatric team, it lets out a strong spontaneous cry. The infant is pink with slightly blue extremities that are actively moving and kicking. The heart rate is noted to be 110 on auscultation. You send a cord gas, which comes back with the following arterial blood values: pH 7.29, Pco2 50, and Po2 20.
241. What Apgar score should the pediatricians assign to this baby at 1 min of life?
242. What condition does the cord blood gas indicate?
a. Normal fetal status b. Fetal acidemia c. Fetal hypoxia d. Fetal asphyxia e. Fetal metabolic acidosis
243. All of the following represent part of routine neonatal care in a healthy infant except a. Administration of silver nitrate to the eyes for prophylaxis for gonorrhea and chlamydia b. Administration of vitamin K to prevent bleeding problems c. Administration of hepatitis B immune globulin for routine immunization against hepatitis B
d. Keeping the infant in a heated, warm crib e. Application of an identification band immediately to the infant
You are making rounds on a 29-year-old G1P1 who underwent an uncomplicated vaginal delivery at term on the previous day. The patient is still very confused about whether or not she wants to breast-feed. She is a very busy lawyer and is planning on going back to work in 4 weeks, and she does not think that she has the time and dedication that breast-feeding requires. She asks you what you think is best for her to do.
244. In your discussion with the patient, you outline all the benefits of breast-feeding. All of the following are accurate statements regarding breast-feeding except a. Breast-feeding is associated with a decreased incidence of neonatal diarrhea b. Breast-feeding is associated with a decreased incidence of sudden infant death syndrome c. Breast-feeding is associated with a decreased incidence of childhood urinary tract infections d. Breast-feeding is associated with a decreased incidence of childhood otitis media e. Breast-feeding is associated with a decreased incidence of childhood attention deficit disorder
245. The patient decides after careful consideration that she is not going to breast-feed. When you go to discharge her to home from the hospital on postpartum day 3, she tells you that her breasts are very engorged and tender. You tell her that she can do all of the following to relieve her breast discomfort except a. Take bromocriptine b. Wear a well-fitting brassiere c. Apply ice packs to her breasts d. Use oral analgesics e. Wear a breast binder
A 36-year-old G1P1 comes to see you for a routine postpartum exam 6 weeks after an uncomplicated vaginal delivery. She is currently nursing her baby without any major problems and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for birth control. She does not have any medical problems. She is a nonsmoker and is not taking any medications except for her prenatal vitamins.
246. All of the following are appropriate methods of birth control for this patient with the exception of a. IUD
b. Minipill c. Depo-Provera d. Combination oral contraceptives e. Foam and condoms
247. The patient calls you on the phone 2 weeks later and is very concerned because she is having pain with intercourse secondary to vaginal dryness. What do you recommend to help her with this problem?
a. Instruct her to stop breast-feeding b. Apply hydrocortisone cream to the perineum c. Apply testosterone cream to the vulva and vagina d. Apply estrogen cream to the vagina and vulva e. Apply petroleum jelly to the perineum
248. A 25-year-old G1P1 comes to see you 6 weeks after an uncomplicated vaginal delivery for a routine postpartum exam. She denies any problems and has been breast-feeding her newborn without any difficulties since leaving the hospital. During the bimanual exam, you note that her uterus is irregular, firm, nontender, and about a 15-week size. Which of the following is the most likely etiology for this enlarged uterus?
a. Subinvolution of the uterus b. The uterus is appropriate size for 6 weeks postpartum c. Fibroid uterus d. Adenomyosis e. Endometritis
A 39-year-old G3P3 comes to see you on day 5 after a second repeat cesarean section. She is concerned because her incision has become very red and tender and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 102 °E Physical exam indicates that the Pfannenstiel incision is indeed erythematous and is open about 1 cm at the left corner, and is draining a small amount of purulent liquid.
249. All of the following are appropriate steps in the management of this patient except a. Open the rest of the incision b. Administer broad-spectrum antibiotics c. Probe the fascia d. Take the patient to the OR for secondary closure of the skin e. Allow the skin to close by secondary intention
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