1. A 20-year-old primigravid woman at 40 weeks’ gestation is admitted in labor. The cervix is 4 cm dilated; the vertex is at 0 station. Two liters of lactated Ringer’s solution are administered. An epidural catheter is placed, and a test does of lidocaine and epinephrine is injected. She immediately has tinnitus and a metallic taste in her mouth. Her blood pressure is 140/100 mm Hg, and pulse is 110/min. Which of the following is the most likely cause of these findings?

2. A 37-year-old nulligravid woman comes to the physician because she has not been able to conceive for 2 years. Her 40-year-old husband has a child by a previous marriage. Her last menstrual period was 6 weeks ago; menses have occurred at increasingly infrequent intervals over the past year. Fifteen years ago, she was treated for one episode of Chlamydia trachomatis infection. She weighs 59kb (130 lb) and is 170cm (67 in) tall. Examination shows no abnormalities. Serum studies show:

β-hCG <5 mIU/mL
Follicle-stimulating hormone 50 mIU/mL
Luteinizing hormone 45 mIU/mL
Prolactin 13ng/mL
Thyroid-stimulating hormone 3 µU/mL

Which of the following is the most likely cause of this patient’s infertility?

3. A 29-year-old woman, gravida 5, para 4, who has been followed in the obstetric clinic, is admitted to the hospital at 30 weeks’ gestation because of mild bright red vaginal bleeding. She has no pain or contractions. Vital signs are stable. Fetal heart rate is 144/min. Which of the following is the most likely adverse fetal outcome?

4. A 40-year-old woman comes to the physician for a health maintenance examination. She had a tubal ligation 6 years ago. She has a history of vulvar condylomata acuminata treated with podophyllum 5 years ago. A Pap smear shows a high-grade squamous intraepithelia lesion. Which of the following is the most appropriate next step in management?

5. Four hours after delivery of a 4082-g (9-Ib) newborn, a 32-year-old woman, is found unconscious. She delivered by forceps in the second stage of labor. Her temperature is 37C (98.6F), blood pressure is 60/40 mm Hg, pulse is 120/min, and respirations are 18/min. Physical examination shows diaphoresis and clammy extremities. Pelvic examination shows an 8-cm right-sided pelvic mass. Her hemoglobin level is 7 g/dL, leukocyte count is 8000/mm3 and platelet count is 175,000/mm3 A portable x-ray film of the chest shows no abnormalities. An EKG shows tachycardia. Which of the following is the most likely diagnosis?

6. A 27-year-old woman, gravida 2, para 1, comes to the physician 3 days after an episode of bright red vaginal bleeding with no uterine contractions or cramping. She has had increasing breast size, morning sickness, and extreme fatigue. Her last menstrual period was 8 weeks ago. Examination shows a uterus consistent in size with a 6-week gestation. Vaginal ultrasonography shows normal fetal heart activity. Which of the following is the most likely diagnosis?

7. Two days after a cesarean delivery for fetal distress, a 27-year-old woman has temperatures to 38.2C (100.8F). 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 level 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?

8. A 17-year-old girl comes to the emergency department 3 hours after the sudden onset of severe lower abdominal pain. Examination shows a 15-cm, smooth, palpable left ovarian mass. Serum α-fetoprotein level is 641 ng/mL. Exploratory laparotomy shows no other abnormalities. Which of the following is the most likely neoplasm?

9. A 32-year-old woman, gravida 6, para 5, is admitted in labor at 38 weeks’ gestation. The membranes have not ruptured. The cervix is 6 cm dilated, and the vertex is at -3 station in a cephalic presentation. Two hours later, the membranes rupture spontaneously, and external fetal monitoring shows the sudden onset of severe variable decelerations. The cervix is now 7 cm dilated. Pelvic examination shows that a segment of umbilical cord is prolapsed in the vagina. Which of the following is the most appropriate next step in management?

10. A patient undergoes non-invasive prenatal screening (cell-free DNA testing (cfDNA)) for fetal aneuploidy, which is highly sensitive and highly specific for Down syndrome. Since this test has a high sensitivity, then if the test is positive we can state:

11. A healthy 42-year-old woman, gravida 2, para 2, comes for a routine health maintenance examination. Menses occur at regular 28-day intervals. She has not been sexually active since the death of her husband 5 years ago. She has smoked a half pack of cigarettes daily for 20 years and drinks one to two glasses of wine weekly. A Pap smear 4 years ago showed no abnormalities and HPV testing was negative. Her maternal grandmother was diagnosed with breast cancer at the age of 82 years. She weights 100 kg (221 lbs) and is 173 cm (68 in) tall. Her blood pressure is 135/85 mm Hg. Physical and pelvic examinations show no abnormalities. Which of the following is the most appropriate screening test for this patient?

12. A 19-year-old woman comes to the emergency department 3 hours after she was sexually assaulted by a casual acquaintance at a party. She is distraught and concerned about her risk for infection. She was sexually active 1 week ago, and she and her partner use condoms for contraception. Her last menstrual period was 10 days ago. Examination shows a small superficial laceration at the introitus. Wet mount preparation shows motile sperm. Which of the following should be included in prophylactic treatment for this patient? 

13. A 24-year-old woman at 35 weeks’ gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated but she says that she has been craving salty foods, and now her feet are so swollen that her shoes do not fit. She has had an 18kg (40lb) weight gain during the pregnancy. She now weighs 80kg (170lb) and is 163cm (64in) tall. Her blood pressure is 120/80mm Hg, pulse is 80/min, and respirations are 16/min. Examination shows moderate edema of the feet; the remainder of the examination shows no abnormalities. Urinalysis shows no protein. Which of the following is the most likely explanation for these findings?

14. A 30-year-old woman comes for examination after being told that her mother has ovarian cancer. There is no other family history of cancer. She has used oral contraceptives for 8 years. In addition to testing for the BRCA gene mutation, which of the following is the most appropriate health maintenance recommendation for this patient?

15. A 37-year-old woman comes to the physician because of copious vaginal discharge and moderate vulvar irritation for 10 days. Examination shows erythema of the vaginal walls and a homogeneous, profuse, yellow discharge. A wet mount preparation of the discharge shows numerous WBCs and motile organisms. Which of the following is the most likely causal organism?

16. A 32-year-old woman, gravida 3, para 2, with type 2 diabetes mellitus is admitted to the hospital in labor at 38 weeks’ gestation. Her first two children were born after normal spontaneous vaginal deliveries. On the admission the cervix is 2 cm dilated, the membranes are intact, and the fundal height is 42 cm. Four hours after admission, the cervix is completely dilated, and the vertex is occiput anterior and at -1 station. Over the next hour, contractions occur every 2 minutes, last 60 seconds and are 60 mm Hg in intensity, but the cervix and stations remain unchanged. Fetal heart tones are normal and reactive. One hour later, her condition remains unchanged. Which of the following is the most likely cause?

17. A 38-year-old woman, gravida 2, para 2, has increasing tension, irritability, and bloating before each menstrual period. At times she feels that she cannot stand it any longer and that she will “explode.” Menses occur at 26-32 day intervals and last 5 days. For the first 24 hours of each period, she has mild cramping that is relieved by over-the-counter analgesics. She uses five sanitary pads on the heaviest day of flow. Physical and pelvic examinations show no abnormalities. Which of the following would be most helpful in arriving at a plan of management? 

18. An 18-year-old woman comes to the physician because of a 3-week history of perineal bleeding and itching. She is sexually active with two partners and does not use contraception. Examination shows multiple warty lesions over the perineum. Which of the following is the most likely mechanism of this patient’s condition?

19. A 25-year-old primigravid woman delivers a 4500-g (10lb) neonate after 2 hours in the second stage of labor. The placenta delivers easily followed by profuse hemorrhaging. Examination shows no abnormalities except for profuse bleeding from the cervical os. Which of the following is the most likely diagnosis?

20. A 20-year-old primigravid woman at 8 weeks’ gestation has nausea and vomiting almost daily. She has lost no weight. Which of the following is the best method of alleviating these symptoms?

21. A 32-year-old woman, gravida 1, para 1, has been unable to conceive for 8 years. She had no difficulty conceiving her first child 10 years ago. Physical and pelvic examinations show normal findings. Her basal body temperature chart is biphasic. Her husband’s semen analysis shows normal findings. Hysterosalpingogram shows filling of both fallopian tubes without spillage of dye into the abdominal cavity and dilation of both fallopian tubes. Which of the following is the most likely explanation for the x-ray findings?

22. A 27-year-old woman, gravida 3, para 3, comes to the physician because of tenderness of the left breast for 2 days. She has been breast-feeding for 2 weeks. Her temperature is 38.4C (101.1F). Examination of the breast shows an erythematous, hard, tender upper outer quadrant. The nipple has fissures. Which of the following is the most appropriate pharmacotherapy?

23. Three days after spontaneous vaginal delivery at 39 weeks’ gestation, a 27-year-old woman, gravida 1, para 1, comes to the emergency department because of a tender left axillary mass that has been enlarging over the past 16 hours. Labor lasted 9 hours. She and her newborn were discharged on the second postpartum day. She is breast-feeding successfully with a good volume of milk. Her temperature is 37C (98.6F), blood pressure is 110/67 mm Hg, and pulse is 75/min. Examination shows a 5 x 5 x 7-cm, mildly tender, nonerythematous, rubbery, left axillary mass in the anterior axillary line. It is not warm. Which of the following is the most likely diagnosis?

24. A 28-year-old nulligravid woman has been amenorrheic since stopping oral contraceptives 6 months ago. She has had mild galactorrhea for 3 months. A pregnancy test is negative. Which of the following is the most likely cause of her condition?

25. An 18-year-old woman comes to the physician because of a 2-year-history of monthly bilateral breast tenderness 3 to 4 days prior to her menstrual periods. Examination shows areas of symmetric diffuse nodularity palpable in the upper outer quadrants of both breasts. Which of the following is the most likely clinical course during her reproductive years?

26. A previously healthy 41-year-old woman, gravida 2, para 1, at 35 weeks’ gestation is brought to the emergency department because of abdominal pain after a motor vehicle collision. She is alert. Her temperature is 37C (98.6F), and blood pressure is 90/60mm Hg. Examination shows the uterus to be consistent in size with gestational age. There is focal tenderness in the fundal area. Fetal heart tones are 130/mm. Laboratory studies show:
Hematocrit 25%
Bleeding time 5 min
Prothrombin time 12 sec
Partial thromboplastin time 28sec
Plasma fibrinogen 250 mg/dL (N=200-400)

Which of the following is the most likely cause of the abdominal pain?

27. A 57-year-old woman comes to the physician because of vaginal bleeding for 3 weeks. He last menstrual period was 6 years ago. Her medications include an angiotensi-converting enzyme (ACE) inhibitor for hypertension and chlorpopamide for type 2 diabetes mellitus. She has never received hormone replacement therapy. Her last Pap smear 5 years ago showed normal findings. She is not sexually active. She weighs 111kg (245lbs) and is 157cm (62in) tall; BMI is 45kg/m2. Her temperature is 37C (98.6 F), blood pressure is 140/84 mm Hg, and pulse is 88/min. Examination shows a small amount of blood at the cervical os. There is a normal-sized uterus and no palpable pelvic masses. Which of the following is the most likely diagnosis?

28. Routine urine culture in a 23-year-old woman at 30 weeks’ gestation shows greater than 100 colonies/mL of Escherichia coli. The primary goal of treatment of her infection is prevention of which of the following disorders?

29. A 24-year-old primigravid woman at 37 weeks’ gestation is admitted because of ruptured membranes and contractions for 6 hours. Contractions occur every 3 minutes and last 45 seconds. The fetal heart rate is 140/min. Clear fluid in the vagina test positive with nitrazine. Which of the following is the most appropriate next step in management?

30. A 37-year-old woman comes to the physician because of swelling and redness of the right breast for 3 days. There is no history of trauma and she is not breastfeeding. She recently immigrated to the USA from the Caribbean. Her temperature is 37.2C (99F), blood pressure is 110/70 mm Hg, her pulse is 75/min, and respirations are 14/min. The right breast is diffusely erythematous, edematous, firm, and nontender; no discrete masses are palpable. There is a 1-cm, mobile axillary node. Mammography shows thickening of the skin and a diffuse increase in breast density; no masses are evident. Which of the following is the most appropriate next step in management?

31. An otherwise healthy 17-year-old girl comes to the physician because she has never had a menstrual period. She weights 54kg (120 lb) and is 142cm (56in) tall. Examination shows webbing of the posterior neck. Her chest is broad with widely spaced, inverted nipples. She has no breast development, and there is scarce pubic and axillary hair. Which of the following is the most likely pelvic anatomy in this patient?

32. A 27-year-old nulligravid woman has been unable to conceive for 2 years. Examination shows normal findings. Hysteroslapingography shows a 4-cm septum in the endometrial cavity. If this patient becomes pregnant, she is at greatest risk for which of the following?

33. A 20-year-old woman comes to the physician because she has never had a menstrual period. Development has been normal otherwise, and there is no history of major illness. Breast development began at age 12 years. Her height, weight, and vital signs are within normal limits. Pubic hair is sparse, and there is no axillary hair. Two small, slightly tender, ovoid masses are palpable in the labia majora. Which of the following findings are most likely on pelvic and rectal examination pertaining to Vagina Uterus Ovaries in that order?

 

34. A 23-year-old woman has had severe dysmenorrhea and pelvic pain for 5 years. Treatment with oral contraceptives and nonsteroidal anti-inflammatory drugs has been ineffective. Her symptoms cause her to miss work monthly. Pelvic examination shows no masses or localized tenderness. Cervical cultures are negative. Leukocyte count is 5000/mm3 and erythrocyte sedimentation rate is 8mm/h. Which of the following is the most appropriate next step in management?

35. A 32-year-old primigravid woman at 14 weeks’ gestation comes to the physician because she is concerned about her risk for developing chickenpox. She is a kindergarten teacher, and seven of her students have developed chickenpox over the past 10 days. Her mother cannot recall whether she had chickenpox as a child, but one of her three siblings did have this disease. Examination shows no skin abnormalities. The uterus is consistent in size with a 14-week gestation. Which of the following is the most appropriate next step in management?