Download ALL APGO UWISE - SHANE, Uwise Comprehensive, OBGYN uwise, UWise, APGO Part 1, Unit 1: Appr and more Exams Nursing in PDF only on Docsity!
ALL APGO UWISE - SHANE, Uwise
Comprehensive, OBGYN uwise, UWise,
APGO Part 1, Unit 1: Approach to the
patient, Obsetrics&Gynecology, U-wise
Maternal-Fetal Physiology, uWISE Unit 2:
Obstetrics A - Normal Obstetrics
A 32-year-old G1P0 woman comes to your office for her first prenatal care visit. She has recently read an article about the rising Cesarean section rate in the United States and asks you about the rate in your hospital. What do you explain as the major cause of higher Cesarean delivery rates? A. The rate of breech presentations has increased B. Less women are having vaginal births after Cesarean C. Obstetricians' reluctance to perform forceps delivery D. Increased rate of fetal macrosomia due to uncontrolled gestational diabetes
E. Rate of twins has increased - CORRECT ANSWER_ -B. The rate of vaginal birth after Cesarean
(VBAC) has decreased in recent years due to studies that showed an increased risk of complications, especially uterine rupture. This is one factor that has led to the increased Cesarean section rate. In addition, although the rate of breech presentation is stable, there are significantly fewer obstetricians who are willing to perform vaginal breech deliveries. Many obstetricians do not perform instrumental vaginal deliveries, such as forceps and vacuum extractions, further contributing to the rising rate. Gestational diabetes is a well-known pregnancy complication with clear clinical guidelines. A 23-year-old G1P0 woman at 40 weeks gestation presents to labor and delivery with contractions. At 10:00 am, her cervical exam is 2 centimeters dilated, 70% effaced and the vertex at 0 station. Clinical pelvimetry reveals an adequate pelvis and membranes are intact. The fetus is in a cephalic presentation and EFW is 3500 gms. Contractions are occurring every 3-4 minutes, based on the external monitor. Her labor slowly progresses and, at 1:00 pm, the patient has spontaneous rupture of membranes. Fetal surveillance remains reassuring. Her cervical exam is 5 centimeters dilated, 100% effaced, and 0 station.
At 4:00 pm, the patient's cervical exam is unchanged. Contractions are occurring every 5-6 minutes. Which of the following is the most appropriate next step in the management of this patient? A. Perform a biophysical profile B. Have the patient ambulate
C. Consent the patient for a Cesarean section secondary to - CORRECT ANSWER_ -E.
A 34-year-old G2P1 woman at 40 weeks gestation, with a history of one prior vaginal delivery, strongly desires an induction of labor, as she is unable to sleep secondary to severe back pain. Her cervical exam is closed, 20% effaced and -2 station. The cervix is firm and posterior. Which of the following is the most appropriate next step in the management of this patient? A. Wait until 42 weeks for induction B. Administer cytotec C. Insert a foley bulb in the cervix D. Perform artificial rupture of membranes
E. Perform a Cesarean delivery - CORRECT ANSWER_ -B. The patient is multiparous at term and
waiting until she reaches 42 weeks may increase the risk of perinatal mortality. Since she is uncomfortable with back pain, it is reasonable to induce labor. Her cervix is unfavorable; therefore, cytotec administration is appropriate prior to pitocin induction. A foley bulb or artificial rupture of membranes cannot be achieved in a patient with a closed cervix. At this time, there are no indications to perform a Cesarean delivery in this patient. A 22-year-old G1P0 woman at 39-weeks gestation presents in active labor. Her pregnancy is complicated by diet controlled gestational diabetes. She has a history of uterine fibroids. On examination, she is found to be 4 cm dilated in breech presentation. An ultrasound confirms the breech presentation, amniotic fluid index is 5, and the estimated fetal weight is 3900 g. Which of the following is the most likely cause of the breech presentation in this patient? A. Gestational diabetes B. Uterine fibroids C. Oligohydramnios
can be indicative of large babies which might place her at additional risk, her gestational diabetes represents her largest risk factor. A 30-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with contractions every 2-3 minutes. Her membranes are intact. Her cervical examination is 5 centimeters dilated, 100% effaced, and -1 station. The fetal heart rate tracing is category I. Two hours later, she progresses to 7 cm and 0 station and receives an epidural for pain. Four hours after that, her exam is unchanged (7/100/0). Fetal heart rate tracing remains category I. Which of the following is the most appropriate next step in the management of this patient? A. Allow her to ambulate and return when she is ready to push B. Perform a contraction stress test C. Perform an amniotomy D. Perform a Cesarean delivery
E. Place an internal fetal scalp electrode - CORRECT ANSWER_ -C. This patient has secondary
arrest of dilation, as she has not had any further cervical change in the active phase for over four hours. Amniotomy is often recommended in this situation. After it is performed, if the patient is still not in an adequate contraction pattern, augmentation with oxytocin can be attempted after careful evaluation. Although the patient requires close monitoring, it is too early to proceed with a Cesarean delivery. An internal scalp electrode is not necessary, since the fetal heart monitoring is reassuring. A 25-year-old G1 woman at term presents in active labor. Her cervix rapidly changes from 7 centimeters to complete dilation in 1 hour. She has been pushing for two hours. The fetal station has changed from - 1 to +1. Fetal heart tracing is category I. The patient is feeling strong contractions every three minutes. Which of the following is the most appropriate next step in the management of this patient? A. Cesarean delivery B. Forceps delivery C. Continued monitoring of labor D. Augmentation with oxytocin
E. Ultrasound for estimated fetal weight - CORRECT ANSWER_ -C. Continued monitoring of
labor is appropriate if clinical evaluation indicates that the fetus is not macrosomic or there is no obvious fetopelvic disproportion. If either were the case, then a Cesarean delivery would be indicated. At this time, there is no fetal or maternal indication to perform a forceps delivery because the station is
+1. Augmentation would be indicated if the contractions were inadequate in intensity or frequency. An ultrasound at this stage of labor is inaccurate and one relies on clinical estimates of weight. A 35-year-old G3P2 woman is at 18 weeks gestation. Her obstetrical history is significant for two previous low transverse Cesarean deliveries. Her first one was performed secondary to arrest of dilation in the active phase at 7cm. She delivered a healthy 3500-gram infant. Her second Cesarean delivery was an elective repeat. She delivered a healthy 3400-gram infant. The patient strongly desires to attempt a VBAC (vaginal birth after cesarean). Which of the following statements is correct? A. The likelihood of a uterine rupture after two Cesarean sections is is approximately 10% B. The likelihood of a successful VBAC is lower in patients with two previous Cesarean deliveries than in women with one prior Cesarean delivery C. The likelihood of a successful VBAC is not affected by the indication of the previous Cesarean delivery
D. The likelihood of a successful VBAC after two Cesarean sections is approximately 30%. - CORRECT
ANSWER_ -B. Women attempting a vaginal birth after Cesarean (VBAC) after one previous low
transverse Cesarean delivery have a 70-80% chance of having a successful VBAC and approximately 70% with two previous cesarean sections. The risk of uterine rupture with a history of one previous low transverse Cesarean section is approximately 1 percent or less. There are no data to demonstrate the exact increased risk of uterine rupture with a history of two previous Cesarean deliveries. The indication for the previous Cesarean delivery may affect the success rate of a future VBAC. Patients who had a prior Cesarean delivery for a nonrecurring indication, such as placenta previa or breech presentation are more likely to have a successful VBAC compared to patients whose previous Cesarean delivery was performed secondary to cephalopelvic disproportion. Prostaglandin induction in this patient would is contraindicated. A 25-year-old G1 woman at 41 weeks gestation presents to labor and delivery with painful contractions every four minutes. Her cervix is 5 cm dilated, 90% effaced. On cervical exam, you are able to feel a fetal body part but it is not the head. Which of the following is the most likely body part you were palplating? A. Foot B. Hand C. Buttocks D. Back
-normal liver enzymes and renal function -normal white cell count -and the ability of the patient to follow up rapidly (reliable transportation, etc.) Most published evidence suggests a significant association of physical and sexual abuse with various chronic pain disorders. The arguments with the new partner allude to possible abuse. Studies have found that 40-50% of women with chronic pelvic pain have a history of abuse. Whether abuse (physical or sexual) specifically causes chronic pelvic pain is not clear, nor is a mechanism established by which abuse might lead to the development of chronic pelvic pain. Women with a history of sexual abuse and high somatization scores have been found to be more likely to have non-somatic pelvic pain, suggesting the link between abuse and chronic pelvic pain may be psychologic or neurologic. However, studies also suggest that trauma or abuse may also result in biophysical changes, by literally heightening a person's
physical sensitivity to pain. - CORRECT ANSWER_ -
A 19-year-old G0 woman presents with lower abdominal cramping. The pain started with her menses and has persisted, despite resolution of the bleeding. She thinks she may have a fever, but has not taken her temperature. No urinary frequency or dysuria are present. Her bowel habits are regular. She denies vomiting, but has mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives and states that her partner does not like condoms. On examination: temperature is 100.2°F (37.9°C); pulse 90; blood pressure 110/60. She is well-developed and nourished and in mild distress. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable
with yellow mucoid disch - CORRECT ANSWER_ -Acute salpingitis
Genital HSV infections are classified as initial primary, initial nonprimary, recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary infection (i.e. no history of previous
genital herpetic lesions, and seronegative for HSV antibodies). - CORRECT ANSWER_ -
Postterm pregnancies are associated with macrosomia, oligohydramnios, meconium aspiration,
uteroplacental insufficiency and dysmaturity. - CORRECT ANSWER_ -
twins. 1 is breach. nbsim - CORRECT ANSWER_ -c-section.
The Institute of Medicine (IOM) has developed guidelines (2009) on weight gain in pregnancy. Historical data show that women who gained within the IOM guidelines experienced better outcomes of pregnancy than those who did not. The recommendations are: underweight (BMI < 18.5 kg/m2) total weight gain 28 - 40 pounds; normal weight (BMI 18.5 - 24.9 kg/m2) total weight gain 25 - 35 pounds; overweight (BMI 25 - 29.9 kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30 kg/m2) total
weight gain 11 - 20 pounds. - CORRECT ANSWER_ -
most common abnormal karyotype encountered in spontaneous abortuses, - CORRECT
ANSWER_ -autosomal trisomy
Caffeine intake can increase the pain associated with fibrocystic breast changes, - CORRECT
ANSWER_ -
A 41 year-old G3P3 woman reports heavy menstrual periods occurring every 26 days lasting 8 days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every 2 hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further
evaluation of this patient's complaint? - CORRECT ANSWER_ -pelvic ultrasound
Question 9 of 50Point value 0 - 1 A 62-year-old G0 postmenopausal woman is being referred to your gynecologic oncology colleague after an office endometrial sample demonstrated a FIGO grade 1 endometrioid adenocarcinoma. The patient has no significant medical, surgical or other gynecologic history. She does not smoke and drinks only occasionally at social events. She takes a multivitamin. Her physical exam is unremarkable. Which of the
following additional tests is indicated for this patient? - CORRECT ANSWER_ -Chest x-ray
concerning for an intra-amniotic infection. Delivery is warranted and in the case of reassuring heart tones, there are no contraindications for labor induction and a Cesarean section is not indicated at this time. Manual vacuum aspiration is more than 99% effective in early pregnancy (less than eight weeks). -
CORRECT ANSWER_ -
A 23-year-old G1P0 woman at 38 weeks gestation, with an uncomplicated pregnancy, presents to labor and delivery with the complaint of lower abdominal pain and mild nausea for one day. Fetal kick counts are appropriate. Her review of symptoms is otherwise negative. Vital signs are: temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 14; fetal heart rate 140s, reactive, with no decelerations; tocometer shows irregular contractions every 2-8 minutes; fundal height 36 cm; cervix is firm, long, closed and posterior. A urine dipstick is notable for 1+ glucose with negative ketones. Which of the following is the most likely diagnosis in this patient? A. Appendicitis B. Gestational diabetes C. Braxton-Hicks contractions D. First stage of labor
E. Dehydration - CORRECT ANSWER_ -Braxton-Hicks contractions
valproic acid and preggers effects - CORRECT ANSWER_ -neural tube defects
A 45-year-old G4P3 woman presents with vaginal bleeding. Last week, she performed a home pregnancy test that was positive. She thinks her last menstrual period was four months ago. The last time she saw her doctor was eight years ago, with the birth of her last child. She has no serious medical problems, has smoked a pack of cigarettes a day since the age of 20, occasionally has a beer and does not exercise. Abdominal examination reveals a soft abdomen and the fundus palpable just below the umbilicus. Pelvic ultrasound reveals a fundal placenta and a fetus measuring 18 weeks with normal cardiac activity. Vaginal examination reveals a 3-centimeter lesion arising off the posterior lip of the cervix. It easily bleeds with palpation and is hard in consistency. Which of the following is the most likely cause of the
bleeding? - CORRECT ANSWER_ -Cervical cancer can unfortunately complicate pregnancies and
presents with bleeding. She is at risk due to lack of screening. Central and lateral cystoceles are repaired by fixing defects in the pubocervical fascia or reattaching it to the sidewall, if separated from the white line. Defects in the rectovaginal fascia are repaired in rectoceles. Uterine prolapse is surgically treated by a vaginal hysterectomy, but this patient already had a hysterectomy. Enteroceles are repaired by either vaginal or abdominal enterocele repairs. Vaginal vault prolapse is treated either by supporting the vaginal cuff to the uterosacral ligaments,
sacrospinous ligament or sacrocolpopexy. - CORRECT ANSWER_ -
Postpartum hemorrhage is defined as bleeding in excess of 500 cc after a vaginal delivery or in excess
of 1000 cc after a Cesarean delivery. - CORRECT ANSWER_ -
Pelvic congestion syndrome is a cause of chronic pelvic pain occurring in the setting of pelvic varicosities. The unique characteristics of the pelvic veins make them vulnerable to chronic dilatation with stasis leading to vascular congestion. These veins are thin walled and unsupported, with relatively weak attachments between the supporting connective tissue. The cause of pelvic vein congestion is unknown. Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces uterine enlargement with selective dilatation of ovarian and uterine veins. This pain may be of variable intensity and duration, is worse premenstrually and during pregnancy, and is aggravated by standing, fatigue and coitus. The pain is
A 28-year-old G0 comes to the office for preconception counseling and the inability to conceive for one year. She and her husband of three years are both in good health. She has normal cycles every 28- days. She has intercourse about once a month, depending on her schedule. She is an airline pilot and travels a lot. Her examination is normal. She asks about when to best have intercourse during her cycle
to maximize her chances of pregnancy. What is the most appropriate advice to give her? - CORRECT
ANSWER_ -Use ovulation predictor kits and attempt intercourse after it turns positive
The risk of uterine rupture with a history of one previous low transverse Cesarean section is
approximately 1 percent or less - CORRECT ANSWER_ -
#1 cause of adverse fetal outcome - CORRECT ANSWER_ -DM
MCC of inherited MR - CORRECT ANSWER_ -fragile X syndrome
MCC of PPROM - CORRECT ANSWER_ -infections (think bacterial vaginosis)
terbutaline and ritodrine are CI in what type of patient for tocolytic? What about magnesium sulfate?
What about indomethacin? - CORRECT ANSWER_ -terbutaline and ritodrine are CI in what type
of patient for tocolytic? -Diabetics What about magnesium sulfate?
-myastenia gravis What about indomethacin? -CI @ 33 weeks d/t to premature ductus arteriosus closure fever, a tender fundus, and elevated white blood cell count, which are concerning for an intra-amniotic infection. Intra-amniotic infcection.
CS vs. labor induction? - CORRECT ANSWER_ -very is warranted and in the case of reassuring
heart tones, there are no contraindications for labor induction and a Cesarean section is not indicated at this time.
Uterine hyperstimulation may cause - CORRECT ANSWER_ -prolonged bradycardia
Milk ejection hormone:
Milk production hormone: - CORRECT ANSWER_ -Milk ejection hormone: oxytocin
Milk production hormone: prolactin Antiretroviral therapy should be offered to all HIV-infected pregnant women to begin maternal treatment as well as to reduce the risk of perinatal transmission regardless of CD4+ T-cell count or HIV RNA level. The baseline transmission rate of HIV to newborns can be reduced from about 25% to 2% with the HAART (highly active antiretroviral therapy) protocol antepartum and continuing through
delivery with intravenous zidovudine in labor and zidovudine treatment for the neonate. - CORRECT
When would we use tocolytics in the setting of Preterm rupture of membrane? - CORRECT
ANSWER_ -Tocolysis may be administered in an attempt to prolong the interval to delivery to gain
time for steroids to obtain maximum benefit for the fetus. The risks of chorioamnionitis with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting lung maturity. This may be reasonable in women without evidence of infection or advanced preterm labor. Admittedly, the likelihood of success in this setting is relatively poor, but the potential benefit to the fetus probably outweighs any maternal complication from tocolysis.
IUGR seen with pre-existing diabtes or gestational diabetes? - CORRECT ANSWER_ -only Pre-
existing diabetes. PR-IUGR. An ultrasound performed between 14 and 20 weeks gestation should be used to date the pregnancy if there is greater than a 10 day discrepancy from the menstrual dates. First trimester ultrasound provides the most accurate assessment of gestational age and can give an
accurate estimated date of confinement (EDC) to within 3-5 days. - CORRECT ANSWER_ -
Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle constrictor, which also has a bronchio- constrictive effect
Why is this important? - CORRECT ANSWER_ -Its use is ContraIndicated w/ tocolysis in asthma
patients.
What factors are ass/w breech presentation? - CORRECT ANSWER_ --Prematurity
-multiple gestation -genetic disorders -polyhydramnios -hydrocephaly
-anencephaly -placenta previa -uterine anomalies -uterine fibroids
tachycardia and sinusoidal heart rate pattern - CORRECT ANSWER_ -abruption placenta
A 22-year-old G1, who is at 38 weeks gestation with an estimated fetal weight of 2500 g, presents in active labor. She is completely dilated and effaced. The fetus is at +4 station and left occiput anterior with no molding. She has an epidural and has been pushing effectively for three hours. She is exhausted.
What is the next step in management? - CORRECT ANSWER_ -This patient meets all the
requirements for an operative vaginal delivery. Forceps application requires complete cervical dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of the fetal head, adequate maternal pain control and rupture of membranes. Strict adherence to the guidelines suggested by the American College of Obstetricians and Gynecologists (ACOG) for low forceps delivery does not increase the fetal or maternal risks when performed by an experienced operator. A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty breathing, cough and frothy sputum. She was admitted for preterm labor 24 hours ago. She is a non-smoker. She has received 6 liters of Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: 100.2°F (37.9°C); respiratory rate 24; heart rate 110; blood pressure 132/85; pulse oximetry is 97% on a non-rebreather mask. She appears in distress. Lungs reveal bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show white blood cell count 17,500/mL with 94% segmented neutrophils. Potassium and sodium are normal. Which of the
following has most likely contributed to this patient's respiratory symptoms? - CORRECT
ANSWER_ -This patient has pulmonary edema.
Endometritis in the postpartum period is most closely related to the mode of delivery - CORRECT
ANSWER_ -3 x higher in C-section.
Also: -prolonged labor -prolonged ROM -multiple vaginal examinations -internal fetal monitoring -removal of the placenta manually -low socioeconomic status A 26-year-old G1 with last menstrual period 10 weeks ago presents to your office for her first prenatal visit. She reports vaginal spotting for the last two days. You perform an ultrasound that shows an intrauterine pregnancy consistent with nine weeks gestation with no cardiac activity. She denies cramping or abdominal pain. What is the most important laboratory test to check for this patient? A. Quantitative beta-hCG B. Maternal blood type C. Hemoglobin and hematocrit D. Platelet count
E. Progesterone - CORRECT ANSWER_ -Maternal blood type
Delivery is indicated in a fetus with IUGR at 36 weeks gestation with oligohydramnios and abnormal umbilical artery Doppler studies. Although there is an increased incidence of fetal intolerance of labor, induction of labor is generally preferred over elective Cesarean delivery. Delivery at term is indicated in
fetuses with IUGR with reassuring fetal testing including a normal amniotic fluid volume. - CORRECT
ANSWER_ -
A 17-year-old G1 woman at 24 weeks gestation presents with vaginal bleeding. She denies any pain, cramping or dysuria. She reports last having intercourse three weeks ago. Prenatal care and labs have been unremarkable. Her vital signs are normal and she is afebrile. Pelvic ultrasound reveals a fundal placenta and viable fetus. Abdominal examination is unremarkable. Vaginal examination reveals a uniformly friable cervix with a small amount of blood in the vault. Digital examination reveals a firm,
closed cervix. What is the most likely diagnosis that explains the bleeding? - CORRECT
ANSWER_ -. Cervicitis caused by chlamydia, gonorrhea, trichomonas or other infections can present
with vaginal bleeding. The cervix is much more vascular during pregnancy and inflammation can lead to bleeding. Evaluation for other causes of bleeding must be completed and then treatment for the infection should be initiated. The patient does not give any history of trauma and cancer is unlikely because of her age. She is not in labor, and a bloody show associated with cervical dilatation is not consistent with the history provided. Threatened abortion occurs during the first trimester. A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and delivery reporting a gush of blood-tinged fluid approximately five hours ago and the onset of uterine contractions shortly thereafter. She reports contractions have become stronger and closer together over the past hour. The fetal heart rate is 140 to 150 with accelerations and no decelerations. Uterine contractions are recorded every 2- minutes. A pelvic exam reveals that the cervix is 4 cm dilated and 100 percent effaced. Fetal station is 0. After walking around for 30 minutes the patient is put back in bed after complaining of further discomfort. She requests an epidural. However, obtaining the fetal heart rate externally has become difficult because the patient cannot lie still. What is the most appropriate next step in the management
of this patient? - CORRECT ANSWER_ -If the fetal heart rate cannot be confirmed using external
methods, then the most reliable way to document fetal well-being is to apply a fetal scalp electrode. Putting in an epidural without confirming fetal status might be dangerous. Although ultrasound will provide information regarding the fetal heart rate, it is not practical to use this to monitor the fetus continuously while the epidural is placed. An intrauterine pressure catheter will provide information about the strength and frequency of the patient's contractions, but will not provide information regarding the fetal status. Closer fetal monitoring via a fetal scalp electrode should be performed. Untreated severe twin-twin transfusion syndrome has a poor prognosis, with perinatal mortality rates of 70-100%. Death in utero of either twin is common. Surviving infants have increased rates of neurological morbidity, with increased risk of cerebral palsy for the surviving twin. Excessive volume can lead to
