1. A newborn is found to have a small open L5-S1 myelomenigocele. She was born at 38 weeks’ gestation to a 37-year-old primigravid woman after a pregnancy complicated by maternal hypertension. Her mother took captopril during the first 2 months of the pregnancy and switched to methyldopa when she found out that she was pregnant. Her mother is a strict vegetarian, and her diet during the pregnancy consisted mainly of cooked vegetables and fruits; she did not use prenatal vitamins. She smoked one half pack of cigarettes daily during the pregnancy. Which of the following measures is most likely to have prevented the myelomeningocele?

2. A 47-year-old woman, gravida 2, para 2, recently discovered a small, firm, painless mass in her right breast during a self-examination. Two years ago, she had a fibroadenoma removed from her left breast. She has no family history of breast cancer. Examination of the breasts shows a 2x1-cm, firm, irregular, mobile mass at the 9-o’clock position in the right breast. No nipple discharge is noted. Needle aspiration of the mass is attempted, but no cellular material is obtained. Mammography shows normal findings. Which of the following is the most appropriate next step in the evaluation of this patient?

3. A 27-year-old primigravid woman at 28 weeks’ gestation comes to the emergency department because of clear, watery vaginal discharge and lower abdominal cramping pain for 12 hours. She also has chills, nausea, and vomiting. She was treated for vaginitis during the first trimester. Her temperature is 38.9 C (102 F), blood pressure is 120/80mm Hg, and pulse is 100/min. The fetal heart rate is 170/min. Examination of vaginal discharge shows pooling and ferning; a nitrazine test is positive. Which of the following is the most likely cause of these findings?

4. A 42-year-old woman is 16 weeks’ gestation comes to the physician for her first prenatal visit. During the examination, amniocentesis is discussed since the patient is at increased risk for an infant with Down syndrome. She says that she would like to undergo amniocentesis to emotionally prepare for a child with Down syndrome, but she intends to carry the pregnancy to term regardless of the screening results. Which of the following is the most appropriate recommendation for this patient?

5. A 15-year-old girl is brought to the physician because she has not started menses. Breast and pubic hair development are Tanner stage 4 with normal axillary hair. She weighs 68kg (150lbs) and is 163cm (64 in) tall. The vagina is of normal length; the cervix and uterus are hypoplastic. Her karyotype is mosaic 45,X/46,XY. This patient is at increased risk for neoplasms of which of the following organs?

6. A 21-year-old primigravid woman has a cesarean delivery because of cephalopelvic disproportion after 24 hours of labor, including 20 hours of ruptured membranes. On the second postoperative day, she develops abdominal pain, uterine tenderness, purulent lochia, and a temperature of 39.4C (102.9F). Initial antibiotic therapy should be directed toward the presumptive diagnosis of endometritis caused by which of the following?

7. A 35-year-old woman, gravida 3, para 2, comes to the physician for her second prenatal visit at 14 weeks’ gestation. Laboratory studies show a positive rapid plasma reagin (RPR). In addition to inquiring about a history of syphilis, which of the following is the most appropriate next step in management?

8. An obese 59-year-old nulligravid woman has had a small amount of vaginal spotting for 2 weeks. Her menses started at the age of 12 years and were always irregular and light. She become sexually active at 16 years and has had 12 sexual partners in her lifetime; she has never used contraception. Menopause began 3 years ago. Her prior Pap smears and pelvic examinations have always been normal. She does not smoke cigarettes but drinks alcohol regularly. She takes no drugs. Which of the following is the most likely site and type of cancer?

9. A 27-year-old woman comes to the physician because of painful vulvar swelling for 2 days. She has had three episodes of Neisseria gonorrhoeae infection treated successfully with oral antibiotics over the past 5 years. Examination shows a 4-cm, tender, fluctuant mass of the labium majus. Which of the following is the most likely diagnosis?

10. A 9-year-old girl is brought to the physician by her mother because of breast development over the past 6 months. Her height and weight are at the 95th percentile. Examination shows no abnormalities. Breast development is Tanner stage 2. She has no pubic hair. Which of the following is the most appropriate next step in management?

11. A previously healthy 22-year-old woman comes to the physician because of urinary frequency and urgency and burning with urination for 3 days. Pelvic examination shows a prudent-appearing cervical discharge and cervical friability. A gram’s stain of the discharge shows gram-negative intracellular diplococci. Urinalysis shows:

RBC 0/hpf
WBC 3-5/hpf
Epithelial cells 0/hpf
Bacteria none

What is the most likely diagnosis?

12. A 26-year-old primigravid woman has cardiopulmonary arrest 3 minutes after vaginal delivery of a 3232g (7lb 2oz) newborn at 42 weeks’ gestation. Labor as induced with oxytocin. Membranes ruptured spontaneously when the cervix was dilated to 7 cm; meconium-stained amniotic fluid was noted. The second stage of labor lasted 2 hours, and mediolateral episiotomy was performed for delivery. Two minutes after delivery, the patient reports shortness of breath and suddenly becomes unresponsive. Her blood pressure is 70/40 mm Hg, and a pulse cannot be palpated. She appears cyanotic and is bleeding from all intravenous puncture sites. She is resuscitated, and laboratory studies show thrombocytopenia, prolonged prothrombin time, decreased plasma fibrinogen level, and increased fibrin split products. Which of the following is the most likely cause?

13. A 25-year-old primigravid woman is admitted to the hospital in labor at 40 weeks’ gestation. Epidural anesthesia is begun. After 8 hours, the cervix is completely dilated, and the vertex is at the introitus in a right occipitoanterior presentation. External fetal monitoring shows severe variable decelerations, tachycardia, and decreased variability. Which of the following is the most appropriate next step in management?

14. A 23-year-old woman comes to the physician 1 day after the acute onset of dysuria and urinary urgency and frequency. She recently became sexually active for the first time. Her temperature is 37C (98.6 F). Examination shows normal external genitalia and no costovertebral angle tenderness. A clean-catch urine specimen shows 30-40 erythrocytes/hpf and 20-30 leukocytes/hpf. Which of the following is the most likely causal organism?

15. A 21-year-old primigravid woman comes to the emergency department because of vaginal bleeding and abdominal cramps for 24 hours. Four days ago, she underwent a right oophorectomy at 9 weeks’ gestation because of torsion of a 6-cm cyst. Preoperative ultrasonography showed a viable fetus with cardiac activity. Pelvic examination shows a dilated cervix with tissue in the vaginal vault. Which of the following is the most likely explanation for the bleeding and pain?

16. An otherwise healthy 53-year-old woman has had increasing urinary frequency over the past 12 months. She has had no dysuria, fever, or flank pain. Physical and pelvic examinations show normal findings. Cystometric examination shows increased involuntary bladder contractions. Urine cultures are negative. Which of the following is the most likely explanation for these findings?

17. A 57-year-old woman, gravida 5, para 5, comes to the physician because of a 1-year history of increasing leakage of urine when she coughs or laughs. She now has to wear an absorbent pad daily. She has a 5-year history of type 2 diabetes mellitus treated with metformin and mild hypertension treated with atenolol for the past 2 years. She underwent a hysterectomy 10 years ago for leiomyomata uteri. She weights 95 kg (210 lb) and is 160 cm (63 in) tall. Her blood pressure is 110/70 mm Hg. Pelvic examination shows normal-appearing external genitalia and a large cystourethrocele. An anal wink reflex is present. When asked to cough, she spontaneously leaks urine from the urethra. Urine dipstick shows trace protein and no glucose. Which of the following is the most likely cause of this patient’s urinary incontinence?

18. A 39-year-old woman, gravida 5, para 4, at 16 weeks’ gestation has had vaginal spotting for 6 hours. Her blood pressure is 160/100 mm Hg, and pulse is 120/min. Examination shows hyperreflexia and a tremor. Urinalysis shows 3+ protein. Fetal heart tones are not auscultated by Doppler ultrasonography. Which of the following is the most likely diagnosis?

19. A 27-year-old primigravid woman at 26 weeks’ gestation comes to the physician because of lagging fundal height growth. Her pregnancy has been otherwise uncomplicated. Examination shows a uterus consistent in size with a 20 week gestation. Ultrasonography shows severe fetal growth restriction (less than the 3rd percentile), fetal holoprosencephaly, cleft lip and palate, and rocker-bottom feet. Which of the following is the most likely diagnosis?

20. A 23-year-old woman has frequent urination, dysuria, and suprapubic pain. She has a 2-year history of recurrent cystitis. A urine sample is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate therapy?

21. A 22-year-old primigravid woman comes to the emergency department at 16 weeks’ gestation because of anorexia and increasingly severe abdominal pain over the past 36 hours. The pain began in the periumbilical area and has localized to the right flank. Her temperature is 38.1C (100.6 F), blood pressure is 110/60 mm Hg, pulse is 100/min and regular, and respiration are 20/min. The right flank is tender to palpation, and the uterus is palpable midway between the pubic symphysis and the umbilicus. Pelvic examination shows no adnexal masses or tenderness. Her hemoglobin level is 12 g/dL, hematocrit is 36%, and leukocyte count is 12,600/mm3 with a shift to the left. Urinalysis and ultrasonography of the abdomen show normal findings. Which of the following is the most appropriate next step in management?

22. A sexually active 32-year-old woman, gravida 2, para 2, has had a mucopurulent cervicovaginal discharge for 4 days. Examination of the cervix shows inflammation. A Gram’s stain of the discharge is negative for intracellular organisms. Which of the following is the most likely site of the causal organism?

23. For 3 months, a 23-year-old woman has had a red rash involving the entire areola and nipple of the left breast; over the past 2 weeks, the rash has become raised, and the nipple has begun to bleed. Examination shows a raised, erythematous area in the circumareolar region over the left nipple with no masses. Which of the following is the most appropriate next step in management?

24. A 35-year-old nulligravid woman has had hirsutism and irregular menses since menarche at the age of 13 years. Menses have always occurred at irregular intervals. Her last menstrual period was 2 months ago and lasted 3 weeks; her previous period was 6 months ago and lasted 12 days. Laboratory studies show:

Hematocrit 20%
Serum Follicle-stimulating hormone 4.2mIU/mL
Luteinizing hormone 14.7mIU/mL
Testosterone 100 ng/dL (N=20-80)

Compared with other women in her age group, this patient is at increased risk for which of the following types of cancer?

25. During a routine prenatal examination of a 24-year-old primigravid woman at 16 weeks’ gestation, blood is drawn for measurement of maternal serum α-fetoprotein level. The result is low multiples of the median. This fetus is at increased risk for which of the following?

26. A 40-year-old woman undergoes repair of the bladder wall, uterus, and small intestine after sustaining a penetrating injury to the abdomen during a motor vehicle collision. Three days after the operation, she has a superficial separation of the incision and discharge of clear fluid. The vertical incision is open for 3 cm below the umbilicus, and a loop of small intestine is visible. Which of the following is the most appropriate next step in management?

27. A 77-year-old woman comes to the physician 2 days after she noticed a mass in her right breast during self-examination. Three months ago, she sustained a fracture of the right tibia as the unrestrained driver in a motor vehicle collision; she now walks with a cane. She has no family history of breast cancer. Examination shows a firm, nontender, ill-defined mass in the upper inner quadrant of the right breast. There is a thickening of the skin over the mass. Mammography shows microcalcifications within a speculated mass. Which of the following is the most likely diagnosis?

28. A 24-year-old primigravid woman at 12 weeks’ gestation comes for her first prenatal visit. She has immune thrombocytopenic purura (ITP) and wants to know whether this condition will affect her baby. Her fetus is at increased risk from which of the following?

29. A 14-year-old girl is brought to the emergency department 1 hour after being raped; the sexual assault included vaginal penetration and ejaculation. Her last menstrual period was 12 days ago. A pregnancy test is negative. Which of the following interventions is most appropriate for emergency contraception?

30. A 16-year-old primigravid girl at 39 weeks’ gestation comes to the hospital because of a severe headache. Her blood pressure is 140/90 mm Hg. She has 3+ proteinuria and 3+ edema. Which of the following should be the first step in her management?

31. A 38-year-old woman, gravida 3, para 1, is admitted to the hospital at 33 weeks’ gestation because of temperatures to 38.9C (102F) and back pain for 2 days. Examination shows costovertebral angel tenderness. She has had mild contractions for 4 hours. Urinalysis is consistent with a urinary tract infection. Intravenous ampicillin therapy is started for suspected pyelonephritis. The fetal heart rate pattern shows tachycardia. Which of the following is the most likely explanation for this pattern?

32. A 15-year-old girl has normal breast development, pubic, and axillary hair. She has a uterus and ovaries but no vagina. Which of the following is the most likely karyotype?

33. On ultrasonography, a 28-year-old primigravid woman at 27 weeks’ gestation has oligohydramnios. Agenesis of the fetal kidneys is confirmed. These findings are most likely to affect development of which of the following fetal sites?

34. A 20-year-old primigravid woman at 40 weeks’ gestation has been in labor for 14 hours. The cervix is fully dilated, and the vertex has been at +2 station for 2 hours. Which of the following is the most likely diagnosis?

35. A 16-year-old girl has had fever, chills, and general malaise for 2 days. She has soreness in the genital area and pain with urination. She is sexually active with one partner. She has never had a sexually transmitted disease or a cold sore. Examination shows numerous genital ulcers and bilateral inguinal lymphadenopathy. Speculum examination is unable to be performed because of discomfort. Which of the following is the most likely cause of these findings?