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DIRECTIONS: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.

106. Which of the following statements concerning abdominal pregnancy is correct?

a. Gastrointestinal symptoms are quite often severe b. Fetal survival is approximately 50%

c. Aggressive attempts should be made to remove the placenta at the time of initial surgery d. It may result in infectious morbidity prior to the diagnosis e. It is usually the result of a primary abdominal implantation

107. Which of the following statements concerning placenta previa is true?

a. Its incidence decreases with maternal age b. Its incidence is unaffected by parity c. The initial hemorrhage is usually painless and rarely fatal d. Management no longer includes a double setup e. Vaginal examination should be done immediately on suspicion of placenta previa

108. A patient at 17 weeks gestation is diagnosed as having an intrauterine fetal demise. She returns to your office 5 weeks later and has not had a miscarriage, although she has had some occasional spotting. This patient is at increased risk for a. Septic abortion b. Recurrent abortion c. Consumptive coagulopathy with hypofibrinogenemia d. Future infertility e. Ectopic pregnancies

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109. A 24-year-old presents at 30 weeks with a fundal height of 50 cm. Which of the following statements concerning polyhydramnios is true?

a. Acute polyhydramnios always leads to labor prior to 28 weeks b. The incidence of associated malformations is approximately 3%

c. Maternal edema, especially of the lower extremities and vulva, is rare d. Esophageal atresia is accompanied by polyhydramnios in nearly 10% of cases e. Complications include placental abruption, uterine dysfunction, and postpar-tum hemorrhage

110. True statements about pregnancy-induced hypertension include which of the following?

a. The incidence varies little around the world b. Women who have had hypertension of pregnancy once have a 10% chance of developing it in a later pregnancy c. Elevations in systolic or diastolic blood pressures do not become diagnostically significant until blood pressure values reach 140/90 mmHg d. Young primiparous women have the lowest incidence e. Having a baby by a different father increases the risk of preeclampsia in a multigravid woman

111. True statements about the twin-to-twin transfusion syndrome include which of the following?

a. The donor twin develops hydramnios more often than does the recipient twin b. Gross differences may be observed between donor and recipient placentas c. The donor twin usually suffers from a hemolytic anemia d. The donor twin is more likely to develop widespread thromboses e. The donor twin often develops polycythemia

112. Which of the following is consistent with a decision to perform a cerclage?

a. Uterine contractions b. Cervix dilated to 3 cm c. Uterine bleeding d. Gestation of 26 weeks e. Chorioamnionitis

DIRECTIONS: Each group of questions below consists of lettered options followed by a set of numbered items. For each numbered item, select the one lettered option with which it is most closely associated. Each lettered option may be used once, more than once, or not at all.

Items 113-117

Match each description with the correct type of abortion.

a. Complete abortion b. Incomplete abortion c. Threatened abortion d. Missed abortion e. Inevitable abortion

113. Uterine bleeding at 12 weeks gestation accompanied by cervical dilation without passage of tissue (CHOOSE 1 TYPE OF ABORTION)

114. Passage of some but not all placental tissue through the cervix at 9 weeks gestation (CHOOSE 1 TYPE OF ABORTION)

115. Fetal death at 15 weeks gestation without expulsion of any fetal or maternal tissue for at least 8 weeks (CHOOSE 1 TYPE OF ABORTION)

116. Uterine bleeding at 7 weeks gestation without any cervical dilation (CHOOSE 1 TYPE OF ABORTION)

117. Expulsion of all fetal and placental tissue from the uterine cavity at 10 weeks gestation (CHOOSE 1 TYPE OF ABORTION)

Items 118-119

A 19-year-old primigravida is expecting her first child; she is 12 weeks pregnant by dates. She has vaginal bleeding and an enlarged-for-dates uterus. In addition, no fetal heart sounds are heard. The ultrasound shown below is obtained.

Sarcoma Botryoides

118. The most likely diagnosis of this woman's condition is a. Sarcoma botryoides b. Tuberculous endometritis c. Adenocarcinoma of the uterus d. Hydatidiform mole e. Normal pregnancy

118. The most likely diagnosis of this woman's condition is a. Sarcoma botryoides b. Tuberculous endometritis c. Adenocarcinoma of the uterus d. Hydatidiform mole e. Normal pregnancy

119. After uterine evacuation, management of the woman described above, who has no clinical or radiographic evidence of metastatic disease, should include a. Weekly hCG titers b. Hysterectomy c. Single-agent chemotherapy d. Combination chemotherapy e. Radiation therapy

120. Indications for instituting single-agent chemotherapy following evacuation of a hydatidiform mole usually include a. A rise in hCG titers b. A plateau of hCG titers for 1 week c. Return of hCG titer to normal at 6 weeks after evacuation d. Appearance of liver metastasis e. Appearance of brain metastasis

121. A 32-year-old G3P3 presents with abdominal pain. Her last menstrual period was 6 weeks ago, and a pregnancy test is positive. The specimen shown below is obtained at laparotomy The most likely diagnosis is

a. Incomplete abortion b. Missed abortion c. Hydatidiform mole d. Tubal ectopic pregnancy e. Ovarian pregnancy

122. A 19-year-old woman comes to the emergency room and reports that she fainted at work earlier in the day. She has mild vaginal bleeding. Her abdomen is diffusely tender and distended. In addition, she complains of shoulder and abdominal pain. Her temperature is 97.6°F, pulse rate is 120/min, and blood pressure is 96/50 mmHg. To confirm the diagnosis suggested by the available clinical data, the best diagnostic procedure is a. Pregnancy test b. Posterior colpotomy c. Dilation and curettage d. Culdocentesis e. Laparoscopy

123. In comparing laparoscopic salpingostomy vs. laparotomy with sal-pingectomy for the treatment of ectopic pregnancy, laparoscopic therapy results in a. Decreased hospital stays b. Lower fertility rate c. Lower repeat ectopic pregnancy rate d. Comparable persistent ectopic tissue rate e. Greater scar formation

124. A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy?

a. Previous tubal surgery b. Pelvic inflammatory disease (PID)

c. Use of a contraceptive uterine device (IUD)

d. Induction of ovulation e. Exposure in utero to diethylstilbestrol (DES)

125. Nausea and vomiting are common in pregnancy. Hyperemesis gravi-darum, however, is a much more serious and potentially fatal problem. Findings that should alert the physician to the diagnosis of hyperemesis gravidarum early in its course include a. Electrocardiographic evidence of hypokalemia b. Metabolic acidosis c. Jaundice d. Ketonuria

126. A 32-year-old G2P0101 presents to labor and delivery at 34 weeks of gestation, complaining of regular uterine contractions about every 5 min for the past several hours. She has also noticed the passage of a clear fluid per vagina. A nurse places the patient on an external fetal monitor and calls you to evaluate her status. The external fetal monitor demonstrates a reactive fetal heart rate tracing, with regular uterine contractions occurring about every 3 to 4 min. On sterile speculum exam, the cervix is visually closed. A sample of pooled amniotic fluid seen in the vaginal vault is fernand nitrazine-positive. The patient has a temperature of 102°F, P = 102, and her fundus is tender to deep palpation. Her admission blood work comes back indicating a WBC of 19,000. The patient is very concerned because she had previously delivered a baby at 35 weeks who suffered from respiratory distress syndrome. You perform a bedside sonogram, which indicates oligohydramnios and a fetus whose size is appropriate for gesta-tional age and with a cephalic presentation. What is the next appropriate step in the management of this patient?

a. Administer betamethasone b. Administer tocolytics c. Place a cervical cerclage d. Administer antibiotics e. Perform emergent cesarean section

Items 127-130

A 30-year-old G1P0 with a twin gestation at 25 weeks presents to labor and delivery complaining of irregular uterine contractions and back pain. She reports an increase in the amount of her vaginal discharge, but denies any rupture of membranes. She reports that earlier in the day she had some very light vaginal bleeding, which has now resolved. She says that the babies have been active and moving as much as usual. She thinks that she may be feeling cramping because she may have overdone it with too much activity and lifting as she is trying to fix up the nursery to get it ready for the babies. She denies any change in her bowel or urine habits. She reports having had regular prenatal care during the pregnancy and denies any prior problems or complications. On arrival to L and D, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 min. She is afebrile and her vital signs are all normal. Her gravid uterus is nontender. The nurses call you to evaluate the patient.

127. All of the following are appropriate next steps in the evaluation of this patient except a. Sterile digital exam b. Intravenous hydration c. Bedside ultrasound d. Urinalyis and urine culture e. Rectovaginal swab for B strep

128. A bedside ultrasound examination indicates that both fetuses are in the cephalic presentation and rules out the presence of a placenta previa. A sterile speculum exam is then performed, and a vaginal swab is obtained to perform a fern test on the vaginal discharge. The fern and nitrazine tests are negative. A subsequent digital exam indicates that the cervix is 50/2-3/-3. All of the following are appropriate next steps to manage this patient except a. Prep the patient for an emergent cesarean section b. Administer tocolytics c. Administer betamethasone d. Administer antibiotics e. Obtain a neonatal consultation

129. A maternal fetal medicine specialist is consulted and performs an in-depth sonogram. The sonogram indicates that the fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. In this clinical picture, all of the following are concerns for twin A except a. Congestive heart failure b. Anemia c. Hypervolemia d. Polycythemia e. Hydramnios

130. All of the following are appropriate tocolytics for this patient except a. Indocin b. Nifedipine c. Terbutaline d. Ritodrine e. Magnesium sulfate

Items 131-135

A healthy 42-year-old G2P1001 presents to labor and delivery at 30 weeks gestation complaining of a small amount of bright red blood per vagina earlier in the day. The bleeding occurred shortly after intercourse. It started off as spotting and then progressed to a light menses. By the time the patient arrived at L and D, the bleeding had completely resolved. The patient denies any regular uterine contractions, but admits to occasional abdominal cramping. She reports the presence of good fetal movements. She denies any complications during the pregnancy. She had a normal screening sonogram at 20 weeks as part of her routine prenatal care. Her obstetrical history is significant for a previous low transverse cesarean section at term for a fetus that was footling breech. She wants to have an elective repeat cesarean section with a tubal ligation for delivery of this baby when she gets to term.

131. All of the following should be included in the list of differential diagnoses for the bleeding except a. Cervicitis b. Preterm labor c. Placental abruption d. Placenta previa e. Subserous pedunculated uterine fibroid f. Uterine rupture

132. What is the appropriate next step in the management of this patient?

a. Send her home, since the bleeding has completely resolved and she is experiencing good fetal movements b. Perform a sterile digital exam c. Perform an amniocentesis to rule out infection d. Perform a sterile speculum exam e. Perform an ultrasound exam

133. The patient is placed on an external monitor after a bedside ultrasound exam reveals a partial placenta previa. No uterine contractions are demonstrated, but she starts to bleed heavily. All of the following are appropriate next steps except a. Administer intramuscular terbutaline as soon as possible b. Type and cross the patient for four units of packed red blood cells c. Administer an intravenous fluid bolus d. Place a Foley catheter e. Call anesthesia

134. The patient continues to bleed, and you observe persistent late decelerations on the fetal heart monitor with loss of variability in the baseline. Her blood pressure and pulse are normal. You explain to the patient that she needs to be delivered. You counsel her regarding all of the following except a. She may require a blood transfusion b. She may require a cesarean hysterectomy c. Tubal ligation is recommended at the time of cesarean section d. The baby may require resuscitative measures at delivery

135. The patient is delivered by cesarean section under general anesthesia. The baby and placenta are easily delivered, but the uterus is noted to be boggy and atonic despite intravenous infusion of Pitocin. All of the following are appropriate agents to use next except a. Methylergonovine (Methergine) administered intramuscularly b. Prostaglandin F2a (Hemabate) suppositories c. Misoprostil (Cytotec) suppositories d. Terbutaline administered intravenously e. Prostaglandin E2 suppositories

Items 136-139

A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had an NSVD, and her baby delivered at 40 weeks and weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a nonsmoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100-120/60-70. During her exam, you note that her fundal height measures only 25 cm.

136. All of the following are possible explanations for this patient's decreased fundal height except a. Oligohydramnios b. Intrauterine growth restriction of the fetus c. The presence of fibroid tumors in the uterus d. Incorrect dates

137. An ultrasound is performed by the maternal fetal medicine specialist. The estimated fetal weight is determined to be in the fifth percentile for the estimated gestational age. The biparietal diameter and abdominal circumference are concordant in size. All of the following are commonly associated symmetric growth retardation except a. Nutritional deficiencies b. Chromosome abnormalities c. Intrauterine infections d. Congenital anomalies

138. All of the following can be used to determine a chromosome analysis of the fetus except a. Amniocentesis b. Chorionic villus sampling c. Percutaneous umbilical blood sampling (PUBS)

d. Fetal umbilical Doppler velocimetry

139. At the time of delivery, the fetus would be prone to all of the following neonatal complications except a. Meconium aspiration b. Hypothermia c. Hyperglycemia d. Polycythemia e. Hypoxia

Items 140-142

A 38-year-old G3P1011 comes to see you for her first prenatal visit at 10 weeks gestational age. She had a previous term vaginal delivery without any complications. You detect fetal heart tones at this visit, and her uterine size is consistent with dates. You also draw her prenatal labs at this visit and tell her to follow up in 4 weeks for a return OB visit.

140. Two weeks later, the results of the patient's prenatal labs come back. Her blood type is A-, with an anti-D antibody titer of 1:4. What is the most appropriate next step in the management of this patient?

a. Schedule an amniocentesis for amniotic fluid bilirubin at 16 weeks b. Repeat the titer in 4 weeks c. Repeat the titer at 28 weeks d. Schedule PUBS to determine fetal hematocrit at 20 weeks e. Schedule PUBS as soon as possible to determine fetal blood type

141. All of the following are scenarios in which it would have been appropriate to administer RhoGam to this patient in the past except a. After a spontaneous first-trimester abortion b. After treatment for ectopic pregnancy c. Within 3 days of delivering an Rh- fetus d. At the time of amniocentesis e. At the time of external cephalic version

142. At 29 weeks gestational age, it becomes apparent that the fetus has developed hydrops. All of the following are characteristics of fetal hydrops except a. Polyhydramnios b. Small placenta c. Pericardial effusion d. Ascites e. Subcutaneous edema

Items 143-145

A 39-year-old G1P0 at 39 weeks gestational age is sent to labor and delivery from her obstetrician's office because of a blood pressure reading of 150/100 obtained during a routine OB visit. Her baseline blood pressures during the pregnancy were 100-120/60-70. On arrival to labor and delivery, the patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. The heart rate strip is reactive and the tocody-namometer indicates irregular uterine contractions. The patient's cervix is 50/2-3/0. Her repeat BP is 160/90. Hematocrit is 34.0, platelets are 160,000, SGOT is 22, SGPT is 15, and urinalysis is negative for protein.

143. Which of the following is the most likely diagnosis?

a. Preeclampsia b. Chronic hypertension c. Chronic hypertension with superimposed preeclampsia d. Eclampsia e. Pregnancy-induced hypertension (gestational hypertension)

144. While the patient is being monitored, she rings the bell for the nurse because she is developing a headache and feels funny. As you and the nurse enter the room, you witness the patient undergoing a tonic-clonic seizure. You secure the patient's airway, and within a few minutes the seizure is over. The patient's blood pressure monitor indicates a pressure of 160/110. You glance over at the fetal heart rate tracing and notice a bradycardia down to the sixties. All of the following are appropriate next steps in the management of this patient except a. Plan for induction of labor with amniotomy and Pitocin b. Prepare for emergent cesarean section because the patient is eclamptic c. Lower the patient's blood pressure with hydralazine d. Begin magnesium sulfate intravenously to prevent recurrent seizures e. Place a Foley catheter

145. All of the following would be indications that the patient is receiving too much MgSO4 and needs her infusion dose lowered except a. Hyperreflexia b. Disappearance of patellar reflexes c. Respiratory depression d. Somnolence e. Slurred speech

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