1.

A 26-year-old female presents to

the emergency room complaining of severe right lower quadrant pain. She is
immediately taken to the operating room for presumed appendicitis. At the time of
her surgery her appendix is normal. The surgeon sees a large mass on the right ovary
and removes the ovary. Frozen section on the mass shows a corpus luteum.
Immediately after the surgery her pregnancy test is found to be positive. She is, by
dates 6 weeks pregnant. You are called as the consulting gynecologist. Your main
concern is the following:

A. The hCG level should double over the next 2 days since she is 6 weeks pregnant
B. Having one ovary will affect her ability to produce hormones
C. Removing the corpus luteum will affect the pregnancy
D. Estrogen production will not be affected
E. She could still have an ectopic pregnancy

2 A 37-year-old woman, gravida 1, para 1, just delivered at term a viable male infant
weighing 3980 grams with APGARs (American Pediatric Gross Assessment Records)
of 9 and 9 at 1 and 5 minutes, respectively. Delivery was via spontaneous vaginal
delivery without any complications. After clamping of the umbilical cord, the baby
takes his first breath. Which event(s) is/are directly responsible for the most efficient
oxygenation of blood inside the lungs?

A. Closure of foramen ovale

B. Closure of ductus arteriosus
C. Closure of foramen ovale and ductus arteriosus
D. Closure of umbilical vein and artery
E. Closure of ligamentum arteriosum and ligamentum teres
3. You are listening to a discussion between two medical students about fetal oxygen
consumption and fetal cardiac output. The first student claims that the fetal cardiac
output is at least two times that of the adult cardiac output since the average heart rate
in the fetus is 140 beats per minutes (two times an adult heart beat). The second
student claims that the fetal oxygen consumption is probably half of adult oxygen
consumption because fetal hemoglobin has twice the affinity for oxygen than adult
hemoglobin. The cardiac output and oxygen consumption in a fetus are approximately
what multiple/fraction of that compared with an adult, respectively?
A. 2;2
B. 3;3
C. 1/2; 1/2
D. 1/3; 1/3
E. 2; 1/2

4. The most oxygenated blood is found in which part of the fetal circulation?
A. Ductus venosus
B. Portal vein
C. Inferior vena cava
D. Ductus arteriosus
E. Descending aorta

5. A 24-year-old woman, gravida 4, para 3, at 18 weeks' gestation dated by her last

menstrual period, receives an ultrasound to confirm her “due date” and to
evaluate fetal anatomy. Her first pregnancy was complicated by delivery of an infant
with spina bifida. Her other two pregnancies were uncomplicated. After confirmation
of her gestational age using biparietal diameter, abdominal circumference, and femur
length data, you scan the fetal ductus venosus. Using ultrasound, which structure
would you see leading into and out of the ductus venosus, respectively?
 A. Pulmonary artery; aorta
B. Inferior vena cava; portal vein
C. Umbilical vein; portal vein
D. Portal vein; inferior vena cava
E. Right atrium; left atrium

6. A 37-year-old woman, gravida 1, para 1, just delivered at term a viable male infant
weighing 3980 grams with APGARs (American Pediatric Gross Assessment Records)
of 9 and 9 at 1 and 5 minutes, respectively. Delivery was via spontaneous vaginal
delivery without any complications. After clamping of the umbilical cord, the baby
takes his first breath. Which event(s) is/are directly responsible for the most efficient
oxygenation of blood inside the lungs?
A. Closure of foramen ovale
B. Closure of ductus arteriosus
C. Closure of foramen ovale and ductus arteriosus
D. Closure of umbilical vein and artery
E. Closure of ligamentum arteriosum and ligamentum teres

7. You are listening to a discussion between two medical students about fetal oxygen
consumption and fetal cardiac output. The first student claims that the fetal cardiac
output is at least two times that of the adult cardiac output since the average heart rate
in the fetus is 140 beats per minutes (two times an adult heart beat). The second
student claims that the fetal oxygen consumption is probably half of adult oxygen
consumption because fetal hemoglobin has twice the affinity for oxygen than adult
hemoglobin. The cardiac output and oxygen consumption in a fetus are approximately
what multiple/fraction of that compared with an adult, respectively?
A. 2;2
B. 3;3
C. 1/2; 1/2
D. 1/3; 1/3
E. 2; 1/2
8. The most oxygenated blood is found in which part of the fetal circulation?
A. Ductus venosus
B. Portal vein
C. Inferior vena cava
D. Ductus arteriosus
E. Descending aorta

9. A 23-year-old primigravida woman just delivered an infant weighing 4350 g by

spontaneous vaginal delivery. After 5 minutes of gentle traction on the umbilical
cord, you deliver the placenta, which appears to be intact. You begin massaging the
uterine fundus and ask the nurse to run 20 U of oxytocin in 1000 mL of lactated
Ringer's solution as fast as possible. After careful inspection of the genital tract, you
notice a second-degree laceration and a 2-cm left lateral vaginal wall laceration,
which you attempt to repair. Suturing is difficult because of brisk bleeding from
above the site of laceration. Physical examination reveals a soft, boggy uterine
fundus. Her vitals are as follows: T = 98.9, BP = 164/92, P = 130, R = 18. Which of
the following is the next best step in management?
A. Oxytocin 10 U direct IV infusion
B. Methylergonovine 0.2 mg IM
C. Prostaglandin F2α 0.25 mg IM
D. Manual exploration
E. Curettage

10. Forty hours ago, a 19-year-old primigravida delivered a viable female infant
weighing 3600 g. The baby's APGARs (American Pediatric Gross Assessment
Records) were 9 and 9 at 1 and 5 minutes, respectively. The patient is breastfeeding
and reports minimal lochia. Review of her labor records reveals that her membranes
were ruptured 7 hours before delivery of her infant. Her vital signs before discharge
from the hospital are as follows: T = 100.8, P = 105, BP = 110/70, R = 16. Her
physical examination is remarkable for slight tenderness in the area of the uterus;
 nonerythematous, nontender firm breasts; and nontender calves. Which of the
following is the best initial step before treatment with antibiotics?
A. Urinalysis and culture
B. Genital tract culture
C. Blood culture
D. Incentive spirometry
E. Uterine curettage

11. A 27-year-old woman, gravida 2, para 1, presents for her first prenatal visit after
testing positive on a home pregnancy test. She reports regular cycles every 35 days.
She denies use of birth control pills, Depo-Provera, or other contraceptive in the last 7
months. The first day of her last menstrual period was April 1, 2007, and the last day
was April 5, 2007. She says her periods always last 4 to 5 days. What is the best
estimate of her due date?
A. January 1, 2008
B. January 8, 2008
C. January 12, 2008
D. January 15,2008
E. June 23, 2008

12. A 16-year-old primigravida presents to labor and delivery with reports of abdominal
pain. Her pain is constant and located in both the right lower quadrant and the left
lower quadrant. There is no radiation and no associated symptoms other than
constipation. The patient ate lunch a few hours ago without any problems. Her vital
signs are as follows: T = 97.8, BP = 108/74, P = 96, R = 14. Physical examination of
the abdomen reveals bilateral tenderness in the lower abdomen. There is no rebound
tenderness or guarding, and costovertebral angles are nontender. Her cervix is closed
and uneffaced, and fetal vertex is high. Urinalysis reveals +1 protein, 0 leukocytes, 0
nitrites, 0 bacteria, and 0–1 blood. Amylase, lipase, and liver enzymes are within
the normal range except for elevated alkaline phosphatase. Her complete blood cell
 count is within normal range except for a white blood cell count of 14,000/mm3.
Which of the following is the best explanation for her abdominal pain?
A. Braxton Hicks
B. Round ligament
C. Urinary tract infection
D. Uterine leiomyoma
E. Liver disease

13. A 20-year-old woman presents to labor and delivery in labor. She has not had any
prenatal care. On examination of her cervix, you palpate a bulging membrane but no
fetal parts. The cervix is 4 cm dilated. Ultrasound demonstrates that the fetal head is
in the fundus, the fetal spine is parallel to the mother's spine, and the knees and hips
are flexed. Both arms are flexed at the elbows. Which of the following is the best
description of fetal lie?
A. Complete breech
B. Incomplete breech
C. Frank breech
D. Vertex
E. Longitudinal

14. A woman presents to your office for prenatal care. She has had two abortions, two
second-trimester miscarriages, one ectopic pregnancy, a fetal demise at 37 weeks'
gestation, and two live births. Her son, who is now 13 years old, was delivered at 34
weeks' gestation by spontaneous vaginal delivery. Her daughter, who is now 10 years
old, was delivered at 38 weeks' gestation by cesarean section secondary to fetal
distress during labor. What are her “Gs and Ps” by simple notation and by
TPAL notation, respectively?
 A. G8 P2; G8 P1142
B. G8 P3; G8 P2142
C. G9 P3; G9 P2142
E. G8 P3; G8 P1142
E. G9 P3; G9 P2152

15. A 34–year-old woman, gravida 2, para 1, at 32 weeks' gestation, presents to your

office for routine prenatal care. She delivered her daughter vaginally at 39 weeks
without any complications. Her past medical history is unremarkable, and her current
pregnancy has been uncomplicated other than occasional Braxton Hicks and
increasing vaginal discharge that is nonpruritic, is the same color as her cervical
mucus, and has been present during most of her pregnancy. Her BP is 108/73, her
temperature is 96.8°F, her fundus measures at 33 weeks, she is 5 feet 4 inches tall,
her prepregnancy weight was 120 lb, and she now weighs 135 lb. She is rubella
nonimmune, hepatitis B surface antigen negative, O + / antibody -, Venereal Disease
Research Laboratory nonreactive, and gonorrhea culture/chlamydia negative. What is
the next best step in management?
A. Rubella antibody test
B. 50g glucose tolerance test
C. 300µg anti-D immune globulin
D. Follow-up in 2 weeks
E. Counseling about appropriate weight gain

16. A 28–year-old woman, gravida 3, para 2, at 5 weeks' gestation, presents to you for
confirmation of pregnancy and possible prenatal care. Her first pregnancy resulted in
vaginal delivery of a viable female infant weighing 3900 g at term. Her daughter has
a bilateral hearing deficit. Her second pregnancy resulted in cesarean-section delivery
of a viable male infant weighing 2900 g at 34 weeks because of pregnancy-induced
hypertension. Her son was born with mild myelomeningocele. She denies family
history of any diseases or problems. She tells you that she is a lacto-ovo vegetarian.
What is the most appropriate advice during this prenatal session?
 A. Supplement your diet with additional iron
B. Supplement your diet with additional vitamin B12
C. Increase your folic acid intake to 10 times your prepregnancy amount
D. Eat plenty of green, leafy vegetables
E. Increase your calcium intake to 1200 mg/day

17. You discover two medical students in the low-risk obstetric clinic debating over the
recommended weight gain in normal pregnancy and the two largest contributions to
weight gain during a normal pregnancy. You agree that the recommended weight gain
during normal pregnancy is about 30 lb give or take a few pounds depending on the
prepregnancy weight. Aside from the weight of the fetus, what is the largest
contributor to weight gain during pregnancy?
A. Blood volume
B. Uterus
C. Placenta
D. Amniotic fluid
E. Breasts

18. A 24–year-old woman, gravida 2, para 1, at 27 weeks' gestation, presents to you for
routine prenatal care. She reports plenty of fetal movement and denies spotting or
regular contractions. She does report increasing vaginal discharge that is white to
yellow in color and has a distinct odor. Her temperature today is 98.2°F and her BP
is 100/60. The fundus measures 28 cm above the symphysis pubis. Her last pregnancy
was uncomplicated. She has no known drug allergy. Her past medical history is
remarkable for asthma (about two wheezing episodes per week and symptom free at
nights). You perform a sterile speculum examination and you notice homogenous,
adherent, white-yellow discharge in the posterior fornix and the cervix, but the
mucosa does not appear inflamed. The pH of the discharge is 5.5. Wet mount displays
30% clue cells. The potassium hydrochloride (KOH) prep is nondiagnostic but has a
strong odor. Which of the following is the best diagnosis and treatment combination,
respectively?
 A. Normal discharge and follow-up in 4 weeks
B. Trichomonas and metronidazole
C. Bacterial vaginosis and clindamycin
D. Chlamydia and erythromycin
E. Candida and fluconazole

19. A 39-year-old woman, gravida 3, para 3, is contemplating pregnancy. She delivered

three healthy boys by vaginal delivery at ages 17,23, and 27 years. Her first
pregnancy was complicated by low birth weight. Her second pregnancy was
unremarkable. She incurred a third-degree laceration after extension of a mid-line
episiotomy upon delivery of her third boy. Her past medical history is unremarkable
other than three to four asthma exacerbations every month. What is she at highest risk
for in her subsequent pregnancy?
A. Asthma exacerbation
B. Fourth-degree laceration
C. Low-birth-weight infant
D. Twins
E. Uterine dysfunction

20. A 34-year-old primiparous woman is seeing you because she is considering a second
pregnancy. She tells you she is afraid to get pregnant given the outcome of her first
pregnancy. At 32 years of age, she delivered a term infant with Down syndrome.
During that gestation, a serum screen for aneuploidy was not performed. Had a
second-trimester multiple marker screen been performed, which of the following
results would have been helpful?
A. Low MSAFP, low estriol, low hCG, low inhibin A
B. Low MSAFP, high estriol, low hCG, high inhibin A
C. Low MSAFP, low estriol, high hCG, high inhibin A
D. High MSAFP, high estriol, low hCG, low inhibin A
E. High MSAFP, low estriol, low hCG, low inhibin A
21. A 28-year-old woman, gravida 6, para 1, presents to your office because she tested
positive on her home pregnancy test. Her last menstrual period occurred 40 days ago.
She normally has regular, 28-day cycles and her periods last 3 to 4 days. She
delivered a preterm infant with her very first pregnancy at the age of 17 years. Her
subsequent pregnancies have been complicated by three miscarriages and an ectopic
pregnancy. She denies any medical problems but admits contracting chlamydia
during her late teens (which she sought treatment for). Which of the following is the
most important initial step in the management of this patient?
A. Qualitative serum β-hCG
B. Quadruple screen (MSAFP, estriol, hCG, inhibin A)
C. Anticardiolipin antibodies
D. Chlamydia antibody levels
E. Transvaginal ultrasound

22. A 33-year-old woman, gravida 3, para 2, at 32 weeks' gestation, presents to you for
her routine prenatal care. She delivered her first baby by cesarean section due to
nonreassuring fetal heart rate pattern on the fetal monitor. Her second baby was
delivered by cesarean section also because she did not want a trial of labor. Both
infants weighed less than 4000 g and are doing fine now. You obtain operative
records of her cesarean sections, which show a Pfannenstiel skin incision and low
classical type of incision of the uterus. Currently, she is interested in vaginal delivery.
What is the best advice you can give her?
A. Vaginal delivery is not recommended because the risk of uterine rupture
approaches 8%
B. Vaginal delivery is recommended because the risk of uterine rupture is less than
1%
C. Vaginal delivery is not contraindicated with a history of two previous cesarean
sections
D. Vaginal delivery is a possibility, but risk of rupture is between 0.5% and 4%
E. Vaginal delivery is a possibility, but risk of uterine rupture is 8%
23. A 41-year-old woman, gravida 8, para 4, at 18 weeks' gestation, presents to you for
her first prenatal visit. She has a history of three therapeutic abortions as a teenager.
She has four healthy children-the first two delivered at 32 weeks' gestation, and her
third and fourth children delivered at 37 weeks' gestation. Her past medical history is
significant for two episodes of pyelonephritis with her first two pregnancies, as well
as a partial bicornuate uterus. What in her history places her at greatest risk for
preterm delivery with this pregnancy?
A. Age
B. Delivery history
C. Therapeutic abortions
D. Pyelonephritis
E. Uterine anomaly

24. A 25-year-old woman, gravida 2, para 1, at 8 weeks' gestation, presents to the high-
risk clinic for prenatal care. Her first pregnancy was complicated by delivery of a
premature infant with respiratory problems. Her past medical history is remarkable
for severe asthma (more than 20 exacerbations per week) for which she uses albuterol
and steroid inhalers. She has type II diabetes mellitus that was treated with oral
hypoglycemic agents before pregnancy. She also tells you she acquired hepatitis C a
few years ago when she used to inject intravenous heroine. She is 5 feet 5 inches tall
and weighs 90 lb. Her blood pressure is 180/98, and her urine dipstick is negative.
Which of the following predisposes her to delivery of an infant with congenital
anomalies?
A. Weight
B. Liver disease
C. Diabetes mellitus
D. Hypertension
E. Intravenous drug history
25. Which combination of markers is suggestive of Down syndrome?
A. AFP ↑, hCG ↓, estriol ↑, inhibin A ↓
B. AFP ↓, hCG ↓, estriol ↓, inhibin A ↓
C. AFP ↑, hCG ↓, estriol ↑, inhibin A ↑
D. AFP ↓, hCG ↑, estriol ↓, inhibin A ↑
E. AFP ↑, hCG ↓, estriol ↓, and inhibin A ↓

26. Which of the following cannot be detected on a second-trimester ultrasound

examination?
A. Anencephaly
B. Renal agenesis
C. Tay-Sachs disease
D. Two-vessel cord
E. Tetralogy of Fallot

27. A 32-year-old woman, gravida 1, para 1, comes to see you for genetic counseling.
Her first child was born with sickle cell disease. She has since remarried, and is
requesting prenatal testing. Which of the following is appropriate to offer the patient
first?
A. Percutaneous umbilical blood sampling at the appropriate gestational age
B. Fetal chromosome analysis
C. Maternal hemoglobin electrophoresis
D. Paternal hemoglobin electrophoresis
E. Multiple markers screening
28. Which of the following procedures poses the lowest risk for fetal loss?
A. Chorionic villus sampling
B. Fetal echocardiography
E. Percutaneous umbilical blood sampling
D. Fetal biopsy
E. Amniocentesis

29. Which of the following is NOT an indication for prenatal diagnosis?

A. Paternal age 45 years
B. Elevated MSAFP
C. Previous child with cystic fibrosis
D. Maternal ventricular septal defect (VSD)
E. Omphalocele detected on second-trimester ultrasound

30. A 23-year-old woman who was seen in the emergency department yesterday for a
superficial gunshot wound to the wrist tested positive on a routine serum ß-hCG
screen. Her cycles have always been regular and occur every 28 days and are 4 days
in duration. She believes she is on day 23 of her current cycle. She denies past
medical history. She does not smoke or consume any alcohol. She does take mega
doses of vitamins, which include 20,000 IU of vitamin A daily. Above which dose of
vitamin A has teratogenicity been noted?
A. 5000 IU
B. 8000 IU
C. 10,000 IU
D. 12,000 IU
E. 20,000 IU
31. A 28-year-old woman, gravida 2, para 1, at 11 weeks of gestation, who just moved
from another state is seeing you for her first prenatal visit. She has an idiopathic
respiratory disease that predisposes her to recurrent lung infections. She tells you that
she can't even count how many radiographs she has received in the last 2 months.
You contact her previous hospital's radiation biologist, who calculates her radiation
exposure at approximately 260 mrad. Which of the following is the likely possible
outcome of this pregnancy?
A. No adverse outcome
B. Growth retardation
C. Spontaneous abortion
D. Bone marrow suppression
E. Mental retardation

32. A 28-year-old woman just tested positive on a home pregnancy test even though she
and her husband use condoms regularly. Her last menstrual period was 36 days ago.
Her periods usually occur every 30 days. Her past medical history is unremarkable
and she denies use of tobacco, alcohol, or drugs. Her only concern is that 3 weeks ago
she received a rubella vaccine and was told by her doctor to not become pregnant for
the next 1 month after administration of the vaccine. Which of the following is the
best advice?
A. YOU should schedule an elective termination as soon as possible
B. You have the option of having a therapeutic abortion within the first trimester
C. Rubella vaccine is not harmful to your fetus
D. Pregnancy outcome is usually favorable even after exposure to this vaccine
E. Live viral vaccines are associated with a fourfold increased risk of malformation

33. A 19-year-old woman, gravida 1, para 0, presents to you at 7 weeks of gestation by

her last menstrual period for prenatal care. Her history and physical examination are
completely unremarkable. You educate her about nutrition and exercise during
pregnancy and perform an in-office transvaginal ultrasound to confirm her gestational
age. You then order routine prenatal labs. While chatting with her, you discover that
 she has a stressful job and likes to use the hot tub at least several times a day in
excess of 4 hours. What is the best advice to give to this patient?
A. You should not use hot tubs during pregnancy
B. Hot tub use in pregnancy is associated with fetal growth restriction
C. Minimize hot tub use in the first trimester because it may cause malformations
D Hot tub use during pregnancy is acceptable as long as it is in short intervals
E. Hot tub use is acceptable as long as water temperature is below 102.5°F

34. An 18-year-old student enjoys drinking once or twice a week with her college friends.
Lately, she has been drinking more than 10 mixed alcoholic beverages each time she
goes out. Although she gets a severe “hangover” after each night of drinking,
she still enjoys drinking alcohol and doesn't believe it causes any harm to her body.
She is an average student at school and is able to keep a part-time job without any
difficulty. She has many friends and is well liked. She claims that everybody around
her drinks as much as she does. She doesn't have a thirst for alcohol throughout the
day, but admits that a month ago she only had to drink four drinks to get the same
“buzz” she gets now with six drinks. Her pattern of alcohol consumption is best
described as:
A. Use
B. Abuse
C. Tolerance
D. Dependence
E. Withdrawal

35. A 30-year-old woman, gravida 2, para 1, at 8 weeks of gestation, likes to drink one
glass of red wine at night with dinner and doesn't believe it will harm her developing
fetus. She drank the same amount throughout her last pregnancy and she delivered a
normal healthy neonate weighing 8 lb 4 oz. Her past medical history is unremarkable
other than an appendectomy. When performing her ultrasound at 18 weeks of
gestation, the ultrasonographer should pay close attention to the anatomy of the
baby's:
 A. Bones
B. Brain
C. Heart
D. Kidneys
E. Vertebrae

36. A 20-year-old woman, gravida 4, para 3, presents to you at 22 weeks of gestation for
routine prenatal care. She has missed her last two appointments. All of her previous
pregnancies were complicated by preterm labor and delivery of small infants with
significant respiratory distress. She has a history of a small inferiolateral myocardial
infarct from the previous year. In the office she appears anxious. Her vital signs are as
follows: T = 99.0, BP = 170/96, P = 135, R = 18. The rest of her physical
examination is unremarkable other than what she describes as “stretch marks”
on her antecubital fossa. Which of the following obstetric complications is most
likely to occur during this pregnancy?
A. Cerebral infarction
B. Chorioamnionitis
C. Placenta previa
D. Placental abruption
E. Seizures

37. A 25-year-old woman, gravida 1, para 0, at 13 weeks of gestation, presents to you for
routine prenatal care. She says her baby moves frequently and keeps her up part of the
night. She also reports increasing vaginal discharge that is odorless and otherwise
asymptomatic. Upon measuring the fundal height, you smell alcohol on her breath.
She fails the finger-to-nose test. The rest of the physical examination is unremarkable.
She has no medical history and denies smoking, alcohol, or drug use. What is the
initial best step?
A. Alcohol and drug screen
B. Prescribe metronidazole and follow-up in 4 weeks
C. Refer her to a social worker
 D. Confront her about your findings
E. See her back in 4 weeks

38. A 35-year-old woman, gravida 3, para 2, at 20 weeks of gestation, is seeing you for a
routine prenatal visit. Today she has no complaints. Her previous pregnancies have
been unremarkable. She has chronic hypertension and a history of a cholecystectomy.
She has no known drug allergies. She is a successful attorney who admits to smoking
marijuana several times a week for relaxation and says she has read several papers
that show no increased risk of congenital anomalies. Her vitals are as follows: T =
97.9, BP = 108/68, P = 100, R = 16. Doppler shows fetal heart rate at 156 bpm. What
is the best course of action during this prenatal visit?
A. Educate her about the possibility of delivering a small infant
B. Refuse to see her if she does not stop using marijuana
C. Refer her to a social worker for possible substance abuse
D. Acknowledge that she is correct about no increased risk of congenital anomalies
E. See her back at 24 weeks of gestation

39. A 25-year-old woman, gravida 2, para 1, at 36 and 4/7 weeks of gestation with a
history of prior cesarean section, presents with abdominal pain and vaginal bleeding.
She admits to using cocaine. Her vital signs are significant for T = 99.9, HR = 120,
BP = 170/100. Fetal heart rate baseline is in the 160s with minimal variability and
repetitive late decelerations. Her blood work is significant for a hemoglobin of 7.5,
platelets of 110,000, and a fibrinogen level of 250 mg/dL. The most likely diagnosis
is:
A. Trauma
B. Cervical polyp
C. Placenta previa
D. Placental abruption
E. Uterine rupture
40. A 39-year-old woman, gravida 5, para 4004, presents at 38 weeks with complaints of
severe headache, abdominal pain, and vaginal bleeding. Her past obstetric history is
significant for an emergent cesarean section in the setting of placental abruption with
her last pregnancy. Her past medical history is significant for chronic hypertension
and tobacco use. Her vital signs are as follows: P = 105, BP = 180/105. Her
examination is significant for right upper quadrant tenderness and a tender uterus. Her
urinalysis shows 3+ protein. The following are all risk factors for placental abruption
except:
A. Hypertension
B. History of previous placental abruption
C. Increased maternal age
D. History of previous cesarean section
E. Multiparity

41. A 20-year-old woman, gravida 1, para 0, at 28 weeks of gestation, arrives to labor and
delivery reporting continuous vaginal bleeding and back pain. She denies sexual
intercourse within the last 48 hours. She also denies trauma to the abdomen. You
perform a pelvic ultrasound and note the fetus in cephalic presentation, amniotic fluid
index of 10, and an anterior-fundal placenta. The fetal monitoring strip displays
coupled contractions. The fetal heart rate baseline is 130 with moderate variability.
Her vitals are as follows: T = 96.8, BP = 110/60, P = 90, R = 16. Examination reveals
about 100 mL of blood in the vaginal vault. Her cervix is closed upon examination.
Which of the following medications would you definitely administer?
A. RhoGAM
B. Terbutaline
C. Oxytocin
D. Betamethasone
E. Indocin
42. A 34-year-old woman, gravida 2, para 1, at 34 and 2/7 weeks of gestation, presents to
labor and delivery reporting painless vaginal bleeding. You immediately perform a
transvaginal ultrasound and note the placenta completely overlying the internal os, a
fetus in cephalic presentation, and an amniotic fluid index of 14. The cervical length
appears closed on speculum examination. Her blood pressure is 110/78 and her pulse
is 106. She has slow, continuous bleeding from her vagina. Fetal monitoring reveals
one uterine contraction every 30 minutes, and the fetal heart rate is reactive. What is
the next best step in management?
A. Magnesium sulfate
B. Hospitalization
C. Vaginal delivery
D. Cesarean section
E. Dexamethasone

43. A 28-year-old woman, gravida 3, para 1, at 37 weeks of gestation, presents to labor

and delivery for a scheduled repeat cesarean section with possible cesarean
hysterectomy. She has a history of two previous low transverse cesarean sections. The
first was because of fetal distress during labor, and the second was an elective repeat
cesarean section. Her current pregnancy has been complicated with complete placenta
previa with occasional spotting and recent hospitalization. Delivery by low transverse
cesarean section is complicated by hemorrhage and hypotension. The patient receives
20 units of packed red blood cells (PRBCs). Which of the following organs is most
likely to malfunction?
A. Adrenal cortex
B. Hypothalamus
C. Kidney
D. Liver
E. Heart
44. A 26-year-old woman, gravida 2, para 1, at 39 weeks of gestation, is admitted to the
hospital in labor with ruptured membranes. Her cervix is dilated 5 cm and is 100%
effaced, and fetal vertex is at +1 station. You place a fetal scalp monitor and an
intrauterine pressure catheter. Fetal monitoring strip reveals five contractions in 10
minutes, and each contraction produces 50 mmHg of pressure. Three hours later, her
cervix is 5 cm dilated and 100% effaced, and fetal vertex is at +1 station. What is the
next best step in management?
A. Augmentation with oxytocin
B. Cesarean section
C. Vacuum delivery
D. Magnesium sulfate
E. Methergine

45. A 22-year-woman, gravida 1, para 0, at 40 weeks of gestation, presents to labor and

delivery reporting regular contractions for the last 2 hours. She denies loss of fluid
from the vagina and reports good fetal movement. Her cervix is dilated 2 cm and 50%
effaced, and fetal vertex is at 0 station. The fetal monitoring strip shows regular
uterine contractions every 2 to 3 minutes. The fetal heart rate baseline is 154 bpm
without decelerations and is reactive. What is the next step in management?
A. Cesarean section
B. Oxytocin
C. Fundal massage
D. Walk for 1 to 2 hours then return to check her cervix
E. Meperidine
46. A 29-year-old woman, gravida 2, para 1, at 32 weeks of gestation, presents to labor
and delivery reporting flank pain, fever, chills, and cramping. She is having
contractions every 3 to 4 minutes, and the fetal heart rate baseline is 180. You check
her cervix and discover a dilation of 3 cm and 100% effacement, and you see that the
fetal head is floating. From the physical examination and from results of the
urinalysis, you conclude that she has pyelonephritis and admit her to the hospital for
intravenous antibiotics, magnesium sulfate to try to slow contractions, and steroids.
Several hours later, you are paged because she is having trouble breathing. Her vitals
are follows: T = 102.1, BP = 110/78, P = 105, R = 28, and oxygen saturation is 96%
on room air. Physical examination reveals that her heart is tachycardic but without
murmurs. You hear bilateral rales over the lung bases. Her abdomen is soft, gravid,
and nontender. She still has costovertebral angle tenderness. There is 2+ pedal edema.
Which of the following is the most likely diagnosis?
A. Complication of pyelonephritis
B. Congestive heart failure
C. Pulmonary embolus
D. Pulmonary edema
E. Respiratory muscle paralysis

47. A 24-year-old woman, gravida 1, para 0, at 39 weeks of gestation, is crowning. The

fetal head is not emerging from the vagina after two pushes. You palpate a thick
hymenal ring of tissue at the introitus. Fetal monitoring strip shows bradycardia after
the third push, so you decide to cut a 3-cm episiotomy that extends through the
hymenal ring and vagina and ends laterally in the perineum. What is the advantage of
this type of episiotomy?
A. Clean surgical incision
B. Avoids fourth-degree laceration
C. Less dyspareunia
D. Commonly used when distance between posterior introitus and anus is large
E. Easier to repair
48. A professor of obstetrics is explaining the seven cardinal movements of labor:
first—the greatest transverse diameter of the fetal head passes through the pelvic
inlet; second—the fetal head descends; third—the fetal chin is brought into close
contact with the fetal thorax; fourth—turning of the occiput toward the 12 o'clock
position; fifth—the uterine contractions extend the fetal vertex anteriorly. What is
the next step?
A. Delivery of the head
B. Rotation of occiput to transverse position
C. Rotation of occiput to posterior position
D. Delivery of anterior shoulder
E. Expulsion

49. A 25-year-old woman, gravida 1, para 0, at 39 weeks of gestation, has been laboring
for a few hours. Her cervix is dilated to 6 cm and 80% effaced, and fetal vertex is at 0
station. Membranes have been ruptured for 20 hours and her labor is being augmented
with oxytocin. The intrauterine pressure catheter detects contractions every 1 to 2
minutes at 80 mmHg of pressure and lasting 2 minutes. Fetal heart rate baseline by
scalp electrode is 90 bpm for the last 2 minutes (FHR baseline 30 minutes ago was
140 bpm). What is the best next step in management?
A. Penicillin
B. Cesarean section
C. Left lateral position
D. Discontinue oxytocin
E. Amnioinfusion
50. A 27-year-old woman, gravida 1, para 0, at 40 and 3/7th weeks of gestation, is in the
middle of the first stage of labor. Her cervix is dilated to 4 cm and a decision has been
made to place an epidural. Prior to placement of the epidural, she receives a 500-mL
bolus of lactated Ringer's to prehydrate her, and augmentation with oxytocin is
begun. Her vitals are as follows: T = 99.1, BP = 110/74, P = 102, R = 18. The fetal
heart rate baseline is 142 bpm with three accelerations every 20 minutes. She is
contracting every 3 minutes. After placement of the epidural, fetal heart rate baseline
drops to 130 bpm, and no accelerations are seen within a 10-minute period. The fetal
heart rate also shows a gradual decline in the middle of each contraction to about 115
bpm and then returns to baseline of 130 bpm. She has contractions every 2 to 3
minutes now. Her vitals at this point are as follows: T = 99.2, BP = 78/56, P = 115, R
= 18. What is the best next step in management?
A. Tylenol
B. Penicillin
C. Intravenous hydration
D. Ephedrine
E. Discontinue oxytocin

51. A 22-year-old woman, gravida 2, para 1, at 41 weeks of gestation, is laboring. Her

cervix is dilated to 8 cm and 100% effaced, and fetal vertex is at +1 station.
Membranes have been ruptured for more than 24 hours, and labor is being augmented
with oxytocin. An amnioinfusion is running because of 3–4+ meconium. Fetal heart
rate by scalp electrode has a baseline of 138 bpm with reduced short-term variability
and occasional mild variable decelerations. You are suddenly called to evaluate a
nonreas-suring fetal heart rate. The tocodynamometer shows six contractions in a 10-
minute period with a pressure of 70 mmHg, and fetal heart rate is now 70 bpm for
more than 3 minutes. She is placed in the left lateral position, oxytocin infusion is
stopped, she is given oxygen by mask, and her intravenous fluid rate is increased.
Fetal heart rate is now 98 bpm. What is the best next step in management?
 A. Cesarean section
B. Vacuum delivery
C. Ephedrine
D. Knee-chest position
E. Terbutaline

52. A 19-year-old woman, gravida 1, para 0, at 38 weeks of gestation, is in active labor.

Her cervix is dilated to 5 cm and fetal vertex is at +1 station. The tocodynamometer
displays contractions every 2 to 3 minutes, lasting 1 minute, and producing 50 mmHg
of pressure inside the uterus. The fetal heart rate by scalp electrode has a baseline of
140 bpm with random sharp decelerations to 70 bpm that return to baseline in 60 to
80 seconds. When this type of deceleration occurs, what is the best description of the
initial acid-base status of the fetus?
A. Respiratory acidosis
B. Metabolic acidosis
C. Uteroplacental insufficiency
D. Asphyxia
E. Increased PCO2

53. A 26-year-old woman, gravida 2, para 1, at 20 weeks of gestation, sees you in the
office for prenatal care. Her fundus measures 18 weeks and you are unable to hear
fetal heart tone by Doppler. You perform an ultrasound and confirm lack of fetal
heart activity and lack of fetal movement. Her last pregnancy was complicated by
severe preeclampsia at 34 weeks that forced her to deliver a preterm baby. She has no
medical problems other than mild asthma. Upon further inquiry she tells you she had
one episode of spotting 4 weeks ago but did not have cramping nor did she pass any
clots or tissue from the vagina. Which of the following is the most descriptive
diagnosis?
A. Threatened abortion
B. Fetal demise
C. Incomplete abortion
D. Spontaneous abortion
E. Missed abortion

54. Chromosomal abnormalities account for the majority of first-trimester spontaneous

abortions. If one was to analyze the chromosomal composition of the products of
conception that are extruded in a spontaneous abortion, which of the following would
be the most common finding?
A. Balanced translocation
B. 45,X monosomy
C. Triploidy
D. Trisomy
E. Mosaicism

55. A 30-year-old woman, gravida 4, para 3, at 12 weeks of gestation, is seeing you for
prenatal care. Her first pregnancy ended with a successful vaginal delivery, at term, of
a healthy boy. Her second pregnancy was uncomplicated and resulted in a cesarean
section with low transverse incision of uterus for breech presentation after failed
external version. Her last pregnancy resulted in the successful “natural” birth of
her daughter. What is the best advice you can give this patient regarding vaginal birth
after cesarean section (VBAC)?
A. You are not a candidate for VBAC
B. You are an excellent candidate for VBAC
C. You are an average candidate for VBAC
D. You should consider a cesarean section given your risk of uterine rupture
E. Your risk of uterine rupture is 1 in 80
56. You are an attending obstetrician in charge of a busy hospital. You are monitoring the
progress of a woman (gravida 2, para 0) who has been in labor for the past 24 hours;
her membranes have been ruptured for 17 hours. Three hours ago, her cervix was 10
cm dilated and 100% effaced. The fetal vertex had reached the pelvic floor and was in
the left occiput anterior position. She has an epidural. The fetal heart rate tracing was
reassuring, and she began pushing. Now, the fetal vertex has reached +2 station
though the fetal vertex feels asynclitic. Given her protracted second stage of labor,
you decide to perform a forceps delivery. What step is not necessary prior to
proceeding?
A. Adequate anesthesia
B. Completely dilated cervix
C. Ruptured membranes
D. An additional obstetrician in the room
E. Confirmation of fetal head position

57. A 24-year-old parturient is at 20 weeks' gestation. Her past medical history is notable
for mitral stenosis secondary to rheumatic heart disease as a child. What physiologic
change places her at risk for the development of heart failure during her pregnancy?
A. Increase in minute ventilation
B. Increase in stroke volume
C. Increase in uterine size
D. Increase in renal plasma flow
E. Increase in red cell mass

58. A parturient at 40 weeks' gestation is scheduled for a magnetic resonance imaging

scan to assess for placenta accreta. The radiologist is unable to complete the study
due to nausea whenever the patient is supine. What do you recommend to the
radiologist?
 A. Antiemetic medication
B. Fasting prior to the study
C. Intravenous fluid loading
D. Tilting the patient to the left
E. Supplemental oxygen

59. A 24-year-old parturient with severe preeclampsia requires urgent cesarean delivery
for nonreas-suring fetal heart rate. The anesthesiologist plans general anesthesia.
Which of the following maneuvers would you recommend to increase the safety for
airway management in this patient?
A. Place a nasogastric tube prior to the anesthetic
B. Have small-diameter endotracheal tubes available
C. Obtain an arterial blood gas prior to induction
D. Administer a bronchodilator prior to induction
E. Hydrate the patient with 2 L crystalloid

60. A 28-year-old parturient at 40 weeks' gestation requires general anesthesia for

cesarean delivery due to umbilical cord prolapse. With induction of anesthesia, there
is a rapid decline of the oxygen saturation. This decline is a result of a decrease in
which lung volume?
A. Dead space
B. Total lung
C. Tidal
D. Residual
E. Inspiratory reserve

61. The pain of the second stage of labor is conveyed by which nerve?
A. Paracervical
B. Ilioinguinal
C. Pudendal
 D. Genitofemoral
E. Iliohypogastric

62. A 25-year-old woman requires cesarean section during epidural anesthesia. Prior to
the injection of local anesthetic, the anesthesiologist administers a test dose of 3 mL
lidocaine 1.5% with epinephrine 1:200,000. The patient complains of tinnitus and a
rapid heart rate. What is the most likely etiology of her symptoms?
A. Anaphylaxis
B. Intravascular injection
C. Intrathecal injection
D. Eclampsia
E. Anxiety

63. A 24-year-old parturient at 40 weeks' gestation is in active labor and requests epidural
analgesia. During epidural placement, the dura is punctured. The patient is at
increased risk for the development of which of the following complications
postoperatively?
A. Leg weakness
B. Backache
C. Headache
D. Hemorrhage
E. Dyspnea

64. A 21-year-old parturient is considering epidural analgesia. Which of the following is

increased in patients with epidural analgesia?
A. Prolonged labor
B. Cesarean delivery
C. Impaired breastfeeding
D. Neonatal depression
E. Cerebral palsy
65. A 33-year-old woman, gravida 2, para 1, who is in the third trimester presents to you
for her first prenatal care. She is not sure of her due date because she has been given
three different dates by three different doctors. She tells you that her periods are
irregular and occur every 21 to 35 days. She has not taken any form of birth control
for the past 2 years. The first day of her last menstrual period was July 19,2006. You
obtain a record of an ultrasound performed in the emergency room on September
5,2007, which showed her to be at 8 0/7 weeks of gestation. You also obtain a record
from her last doctor who performed an ultrasound on December 22, 2007, which
showed her to be at 24 3/7 weeks of gestation. Which one of the following is the best
estimate of her due date? (You can use a pregnancy wheel.)
A. April 7, 2008
B. April 8, 2008
C. April 19, 2008
D. April 24, 2008
E. April 26, 2008

66. A 22-year-old woman, gravida 1, para 0, at 15 weeks of gestation by her last

menstrual period, presents to you for an ultrasound examination to confirm her due
date. Which of the following measurements on the fetus is the best at predicting her
actual due date?
A. Crown-rump length
B. Biparietal diameter
C. Abdominal circumference
D. Femur length
E. Head circumference
67. A 25-year-old woman, gravida 3, para 0, at 42 weeks of gestation, presents to your
clinic for prenatal care. She has accurate dating and has been receiving twice-weekly
NSTs for the last week. Underdevelopment of which structure in the fetus may
contribute to prolongation of this woman's gestation?
A. Cerebral cortex
B. Thalamus
C. Thymus
D. Adrenal cortex
E. Ovary

68. A 34-year-old woman, gravida 3, para 1, abortions 1, at 42 1/7 weeks of gestation by

a week-6 ultrasound, presents to your clinic. Her NST is reactive and amniotic fluid
volume (AFV) is 8.5. Her cervix is 0.5 cm dilated, 20% effaced, midposition, and
firm, and the fetal vertex is at -4 station. Which of the following is the best next step
in management?
A. Oxytocin
B. Prostaglandin analog
C. Twice-weekly NST
D. Repeat modified BPP (NST and AFV)
E. Artificial rupture of membranes (AROM)

69. A 25 year-old woman, gravida 3, para 2, comes to labor and delivery at 30 weeks of
gestation complaining of regular uterine contractions. Cervical examination reveals 3
cm of dilation and 80% effacement. The patient is administered corticosteroids and
tocolytics. The contractions persist despite adding a second tocolytic agent and the
obstetrician proceeds with amniocentesis. The amniotic fluid findings reveal presence
of bacteria on Gram stain. The next best step is to:
A. Continue tocolytics until 48 hours are completed
B. Discontinue the tocolytic therapy
C. Send the fluid for lecithin-to-sphingomyelin ratio
 D. Send a maternal serum specimen for complete blood count
E. Administer the second dose of betamethasone 24 hours after the first dose

70. A 28-year-old woman, gravida 3, para 2, at 28 weeks of gestation, has been admitted
to the hospital for several days to treat her preterm labor. Her cervix was dilated to 3
cm and 100% effaced when MgSO4 was started at 2.5 g/hr after a bolus over 30
minutes. An entire workup for preterm labor was done, and she received antibiotics
and steroids. Currently, she has three to four contractions per minute that she barely
feels on 2 g/hr. Treatment with MgSO4 is most likely to:
A. Reduce rate of preterm birth
B. Reduce morbidity associated with preterm delivery
C. Reduce mortality associated with preterm delivery
D. Stop contractions
E. Delay delivery for 2 days

71. A 22-year-old woman, gravida 1, para 0, at 33 weeks of gestation, presents to labor

and delivery and reports cramping and lower back pain. She denies leaking of fluid
from the vagina. You perform a speculum examination that shows no pooling, and
Nitrazine paper stays yellow after contact with the secretions in the posterior fornix.
Cervical cultures are taken. She is placed on fetal heart rate and uterine contraction
monitoring, which shows a baseline heart rate of 155 beats per minute and three
uterine contractions per a 10-minute period. Her cervix changes from closed and 50%
effaced to 2 to 3 cm and 80% effaced. The next best step in management of this
patient is:
A. Antibiotics
B. MgSO4
C. Terbutaline
D. Corticosteroids and tocolytic therapy
E. Ultrasound
72. A 29-year-old woman, gravida 3, para 1, spontaneous abortions 1, at 30 weeks of
gestation, is in preterm labor. She has received an initial bolus of 6 g of MgSO4 over
30 minutes, and she has been placed on a maintenance rate of 4 g/hr for the last 2
days to reduce her contraction pattern to one every 15 minutes (her contractions are
barely noticeable to her). Currently, her vitals are as follows: P = 88, BP = 90/50, R =
9, SaO2 = 95% on room air. Her deep tendon reflexes are 0 bilaterally. She has
crackles on her lung bases on deep inspiration. The next best step in management is:
A. Serum magnesium level
B. Calcium gluconate
C. Switch to terbutaline
D. Discontinue MgSO4
E. Re-evaluate her cervix

73. You have been seeing a 23-year-old woman, gravida 1, para 0, at 28 weeks of
gestation, throughout her pregnancy. She has no known medical history. She denies
blurry vision, epigastric or right upper quadrant pain, severe headache, or trouble
breathing. Her blood pressure and urine protein dipstick results for the past three
visits are as follows: visit 1, BP = 105/60, Udip = 0; visit 2, BP = 110/65, Udip = 1+;
visit 3, BP = 115/68, Udip = 1+. Today her BP = 120/75 and Udip = trace. She reports
lots of fetalmovement. Her fundus measures 25 cm. Lungs are clear to auscultation
bilaterally. Deep tendon reflexes are 2+ symmetric. Results from laboratory studies
you sent on visit 3 are the following:
 Leukocytes = 10,400/mL
 Peripheral Platelet count = 130 × 103/mm3
 blood smear = no hemolysis
 Aspartate aminotransferase = 340 U/L
 Alanine aminotransferase = 200 U/L
 Blood urea nitrogen = 12 mg/dL
 Creatinine = 0.6 mg/dL
 Uric acid = 6.0 mg/dL
 Glucose =105 mg/dL

The most accurate diagnosis for this patient is:

A. Chronic hypertension
B. Gestational hypertension
C. Mild preeclampsia
D. Severe preeclampsia
E. Superimposed preeclampsia on chronic hypertension

74. A 20-year-old primigravid woman at 37 weeks of gestation (confirmed by a first-

trimester ultrasound) presents to the clinic for routine prenatal care. She reports active
fetal movement and abdominal pain. Her blood pressure is 162/103 initially and she
has 2+ protein on the urine dipstick. Her physical examination is unremarkable except
for diffuse tenderness on the abdomen; however, there is no rebound tenderness. Her
fundus measures 36 cm above the symphysis pubis. You send her to labor and
delivery where a complete blood cell count, liver enzymes, electrolytes, uric acid,
urinalysis, and coagulation profile are drawn. On labor and delivery, her blood
pressure is 166/104 and there is 3+ proteinuria on urine dipstick. Her cervix is closed,
long, firm, and posterior, and fetal vertex is high. What is the next step in
management?
A. Oxytocin
B. Prostaglandin analog and magnesium sulfate
C. Magnesium sulfate
D. Methyldopa
E. Hydralazine

75. A 26-year-old primigravida at 35 weeks' gestation complains of mild headache and

facial edema. Her blood pressure is 160/100 and her reflexes are brisk. You suspect
that she has preeclampsia. Her urinalysis is likely to show which of the following?
 A. Proteinuria
B. Hematuria
C. Glycosuria
D. Ketonuria
E. Leukocytes

76. The diagnosis of preeclampsia would be advanced to eclampsia if the woman in

Question 1 developed which of the following?
A. Severe, unremitting headache
B. Clonus
C. Grand mal seizures
D. Petit mal seizures
E. Visual scotomata

77. A 26-year-old nurse, gravida 2, para 1, at 32 weeks of gestation, presents to labor and
delivery (L&D) because of elevated blood pressures. She says her systolic blood
pressures have been in the high 170s and her diastolic blood pressures have been in
the low 110s. She denies abdominal pain, visual disturbances, or severe headache.
Her blood pressure at L&D is 150/98 and she has 1+ proteinuria. You send off
appropriate labs, admit the patient to the hospital, and keep her on bedrest. Which of
the following is an appropriate next step in management?
A. Induce labor vaginal delivery
B. Cesarean section
C. Phenytoin
D. Labetalol
E. Betamethasone

78. A 35-year-old woman, gravida 5, para 1, at 6 weeks of gestation, is seeing you

because she just found out she is pregnant. She has a 6-year history of essential
hypertension controlled on a diuretic agent. After you perform a routine prenatal
 examination, you change her blood pressure medication to methyldopa and ask her to
use it throughout the entire pregnancy. Which of the following is the best reason for
using methyldopa in a patient with chronic hypertension during pregnancy?
A. It is the best antihypertensive during pregnancy
B. It decreases the risk of IUGR in the fetus
C. It decreases the risk of abruptio placentae
D. It decreases the risk of maternal end-organ damage
E. It increases uteroplacental perfusion

79. Which of the following is an independent risk factor for pregnancy-induced

hypertension?
A. Multiparity
B. Family history of chronic hypertension
C. Age older than 40 years
D. Age younger than 20 years
E. History of seizure disorder

80. Which of the following might be found in a patient with MILD preeclampsia?
A. Oligohydramnios
B. Proteinuria in excess of 3 g per 24 hours
C. Thrombocytopenia
D. Intrauterine growth restriction
E. Elevated transaminases

81. A 24-year-old primigravida is seeing you for her first prenatal visit. After confirming
her pregnancy, you take a complete history and perform a physical examination. She
has had type 2 diabetes for 6 years now and has been on oral medications for blood
 sugar control. Her capillary blood glucose level is 110 mg/dL today. After delivery,
her newborn will be at risk for:
A. Elevated blood glucose
B. Low hematocrit
C. Low calcium
D. Elevated potassium
E. Lowbilirubin

82. A 22-year-old woman, gravida 2, para 0, at 22 weeks of gestation, presents to you for
her routine prenatal visit. She has been seeing you throughout her pregnancy. She had
diabetes prior to becoming pregnant and was taking an oral hypoglycemic agent to
control her blood sugars. However, since becoming pregnant, she has been self-
administering daily regular and NPH (neutral protamine Hagedorn's) insulin. Today,
she reports lower back discomfort. Her fundus measures 21 cm and she has 1+
glucose on urine dipstick. Her average fasting blood sugar is 93 mg/dL, and her 2-
hour postprandial sugar is 119 mg/dL. What is the next step in management of this
patient?
A. Adjust her insulin
B. Measure maternal serum AFP
C. Perform fetal ultrasound
D. Perform fetal echocardiograph
E. Perform magnetic resonance imaging (MRI) of the spine

83. A 28-year-old woman, gravida 2, para 1, at 20 weeks of gestation, presents with

increased sweating and palpitations. Her fundus measures 17 cm. T = 98.8, BP =
 115/80, P = 132, R = 16. She is found to have elevated total T4, total T3, and free T4,
and TSH less than 0.1. What is the initial step in management of this patient?
A. Propranolol
B. Methimazole
C. Propylthiouracil
D. Potassium iodide
E. Fetal ultrasound

84. An 18-year-old woman, gravida 3, para 2, at 28 weeks of gestation, is admitted with

right-sided back pain, fever, chills, and severe nausea. She has bilateral costovertebral
angle tenderness, with greater discomfort on the right side. T = 102.6°F, with
normal complete blood count (CBC), blood urea nitrogen (BUN), and creatinine.
Urinalysis revealed more than 100 WBC/hpf. After 3 days of culture-appropriate
antibiotics, her temperature is still 103°F. The next step is:
A. Repeat urine culture
B. Repeat CBC
C. Change antibiotics
D. Perform an ultrasound
E. Perform an intravenous pyelogram (IVP)

85. A 20-year-old woman just delivered a viable male neonate at 38 weeks of gestation
after being a restrained passenger in a car accident. Upon arriving at the emergency
department she was “cleared” by the trauma and orthopedic teams and sent to
the labor and delivery floor. There she began having vaginal bleeding and then went
into labor spontaneously. The estimated blood loss with delivery was 900 mL, and
now she is stable. After obtaining her prenatal information you realize she is Rh
negative and antibody D negative. The next step is:
A. Perform a CBC
B. Transfuse packed red blood cells
 C. Perform a Kleihauer-Betke test
D. Give additional Rh immune globulin
E. Assess neonatal Rh antigen status

A 24-year-old woman, gravida 1, para 0, at 24 weeks of gestation by her last

menstrual period, presents to the emergency department because of vaginal bleeding.
T = 97.8, BP = 135/88, P = 105, R = 16. Her fundus is below the umbilicus and there
are no fetal heart tones on Doppler. On speculum examination you see blood
emerging from an undilated external os, but no lesions are seen on the cervix or the
vaginal walls. Her quantitative hCG level is 85,000 mIU/mL. You are awaiting a
formal ultrasound by a radiologist to confirm your suspicion of a molar pregnancy.

86. What is the most likely explanation for this scenario?

A Maternal 0 + Paternal Y (which duplicates)

B Maternal 0 + Paternal X (which duplicates)
C Maternal Y + Paternal X (which duplicates)
D Maternal X + Paternal X + Paternal X
E Maternal Y + Paternal X + Paternal Y

87. Which of the following findings is the most likely on pelvic ultrasound examination?

A A fetus with biparietal diameter consistent with 22 weeks

B Two-vessel umbilical cord
C Two separate placentas
D Left ovary 6 cm and right ovary 3 cm
E Left ovary 6 cm and right ovary 6 cm

88. A 33-year-old woman, gravida 4, para 3, at 16 weeks of gestation by her last

menstrual period, presents to labor and delivery complaining of vaginal bleeding. Her
 vital signs are as follows: T = 98.9, BP = 150/94, P = 103. Fundal height measures 23
cm. A pelvic ultrasound examination reveals a uterus with a diffuse indistinct mass
filling the endometrial cavity, and no fetal parts are seen. A dilation and suction
curettage is performed and 10 minutes afterwards she is placed on a dilute
intravenous oxytocin drip. Complications involving which one of the following
organs are most likely to occur at this time?
A. Liver
B. Kidney
C. Vagina
D. Lung
E. Brain

89. A 27-year-old nulliparous woman presents to the emergency room reporting

hemoptysis. She has no medical history other than a pregnancy 3 months ago that
resulted in spontaneous abortion. She also has had intermittent vaginal spotting since
the miscarriage. Her BP = 110/70 and P = 88. Significant labs are hemoglobin = 9.6
mg/dL and quantitative β-hCG = 35,000 mIU/mL. Her chest radiograph shows
several masses in the right middle lobe. Which of the following is the best treatment
option for her?
A. Dilation and curettage
B. Hysterectomy
C. Methotrexate and leucovorin
D. Actinomycin D
E. Methotrexate, actinomycin D, and etoposide

90. A 36-year-old multiparous woman just underwent a hysterectomy because of a molar

pregnancy. Other than her treatment for gestational trophoblastic disease, she has no
 medical problems. She had an appendectomy 3 years ago. She is allergic to penicillin
and, although she does not smoke, she admits to drinking at least three to four
alcoholic beverages per day. You obtain a β-hCG 2 days after the operation. What is
the next best step in management of this patient?
A. β-hCG in 1 week
B. β-hCG in 1 month
C. Methotrexate
D. Levonorgestrel plus ethinyl estradiol
E. Chest radiograph in 1 month

91. A 24-year-old woman, gravida 1, para 1, is seeing you because every month since age
19 she has had severe lower pelvic pain during her periods. She says the pain is
similar to “labor pains” and it interferes with her ability to concentrate at work
and during leisure activities on the weekends. Her pain has also caused her to become
extremely anxious and irritable. She has tried acetaminophen with little relief. She
denies having a depressed mood or changes in sleep, energy, or eating patterns. Her
past medical history is remarkable for mild asthma controlled with albuterol. She is
sexually active, is in a monogamous relationship, and uses condoms for
contraception. She has no known drug allergies but admits to drinking a few alcoholic
beverages every day. The next step for this woman is:
A. Ibuprofen
B. Norgestimate plus ethinyl estradiol
C. Fluoxetine
D. Calcium
E. Leuprolide

92. Two female medical students are having a discussion about ovarian reserve. Medical
student #1 claims that because women are born with a finite number of follicles and
 because she has been taking birth control pills since age 16, she has slowed down loss
of her follicles every month by inhibiting ovu-lation. Medical student #2 claims that
because she has been pregnant more times than medical student #1, she has a higher
ovarian follicle reserve. Which of the following statements is true?
A. Medical student #1 has slowed down depletion of her eggs
B. Medical student #2 has slowed down depletion of her eggs
C. Medical student #1 has higher ovarian reserve than medical student #2
D. Both students have slowed down depletion of their eggs
E. There is no way to slow down depletion of eggs

93. Hormone X and Y are secreted in the follicular phase and are responsible for
suppressing FSH in the late follicular phase prior to ovulation. Hormone Z is
responsible for allowing the oocytes to progress through to metaphase II. What are
hormones X, Y, and Z respectively?
A. Estrogen, progesterone, and LH
B. Estrogen, inhibin A, and FSH
C. Estrogen, activin, and FSH
D. Estrogen, inhibin A, and LH
E. Estrogen, inhibin B, and LH

94. Many infertility patients undergo in vitro fertilization (IVF) and embryo transfer (ET)
in order to become pregnant. IVF-ET uses many of the principles of the normal
menstrual cycle to achieve pregnancy. The patients are given FSH hormone to
stimulate multifollicular development, just as occurs in the normal menstrual cycle.
Human chorionic gonadotropin is used to “trigger” the ovulation process
because it is an analog of LH hormone. Supplemental progesterone is given after the
oocytes are retrieved to support the endometrium for implantation. Multiple follicles
develop because:
A. In an IVF cycle LH hormone is not needed for follicular development
B. There is excess FSH available
 C. hCG is more potent than natural LH
D. FSH induces LH release
E. Progesterone is not given until after the oocytes are retrieved

95. A 24-year-old nulligravid woman presents to your office because of amenorrhea of 4

months' duration. She was started on birth control pills at the age of 18 due to
irregular menses. She continued the pills until 4 months ago when she was in a
terrible motorcycle accident and had to undergo multiple surgeries on her face to
repair fractures. Her past medical and surgical history is unremarkable. Her physical
examination is normal. You obtain labs, which reveal the following: hCG less than 5
mIU/mL, prolactin = 12, TSH = 2.2, FSH = 67, estradiol less than 30 pg/mL. Which
one of the following is the most likely diagnosis?
A. Stress-induced amenorrhea from the accident
B. Swyer syndrome
C. Turner syndrome
D. Androgen insensitivity syndrome
E. Müllerian anomaly

96. An 18-year-old nulligravid female is seeing you because she has not had a period for
the last 8 months. She is a freshman in college majoring in dance. She enjoys hiking
to relieve stress. She is sexually active. She began her menses at age 13 and had
irregular periods for the first 2 years and then became regular. She is 5 feet 8 inches
tall and weighs 90 lb. Her vitals are as follows: T = 96.6, BP = 108/60, P = 52. On
examination, she has a normal-appearing vulva and appropriate-sized vagina without
any lesions. Her cervix and uterus are unremarkable. You do not appreciate any
adnexal masses or tenderness. The rest of her physical examination is unremarkable
other than her teeth, on which you see erosion of the upper and lower incisors,
especially posteriorly. She also has small scars on the back of her hands. The most
likely hormone abnormality in this patient is
A. Increased T4
B. Decreased FSH
C. Increased TSH
D. Decreased cortisol
E. Increased prolactin

QUESTIONS 3 & 4
A 25-year-old nulligravid female presents to your office because she has not had a period
for the last year. She didn't think too much of it initially due to her hectic schedule,
but is concerned now because she recently started a serious relationship. Although
she admits she is not yet ready to become pregnant, she wants to have regular periods.
She has no significant medical or surgical history. She started her periods at age 12
and they became regular at age 14 until last year. She has never had a major illness.
She has no known allergies to medications. She is a major bank executive who travels
across the United States and Europe often. She runs 5 miles a day and uses a Jacuzzi
often to relax. Her vital signs are as follows: T = 98.9, BP = 135/86, P = 100. Her
physical examination reveals a height of 5 feet 6 inches and a weight of 132 lb. The
rest of her examination is unremarkable. Labs are as follows: TSH = 1.7, prolactin =
11, FSH = 5.0, estradiol = 45.

97. Abnormality of which structure most likely accounts for her amenorrhea?
A Hypothalamus
B Pituitary
C Ovaries
D Uterus
E Vagina

98. The best next step in management of this patient is:

A Norgestimate and ethinyl estradiol

B Conjugated estrogen and medroxyprogesterone acetate
C Clomiphene
D GnRH pump
E Buspirone

99. A 16-year-old presents to you because she has never had a period. She has no past
medical or surgical history. She has never had a major illness. She has no known drug
allergies. She is a senior in high school and has been accepted to an Ivy League
university. In addition to her excellent academic performance, she is active as a
volunteer in the community and enjoys tennis and volleyball. She is 5 feet 7 inches
tall and weighs 125 lb. Her vital signs are as follows: T = 98.7, BP = 110/70, P = 70.
Her abdomen is unremarkable. She has Tanner stage 4 breast development, axillary
hair growth, and pubic hair growth onto her thighs. On sterile speculum examination
you discover a short vagina that ends blindly. The diagnosis is:
A. Androgen insensitivity syndrome
B. Swyer syndrome
C. 17α-hydroxylase deficiency
E. Mayer-Rokitansky-Küster-Hauser syndrome
E. Kallmann syndrome

Polycystic Ovary Syndrome

100. A 21-year-old nulliparous woman comes to your office reporting several years of
irregular menses, occurring only four to five times a year. On physical examination
you notice hair on her neck, chin, upper lip, and lower abdomen. Your laboratory
workup of this patient should include all of the following EXCEPT:
A. Thyroid-stimulating hormone
B. Serum testosterone
C. 170H progesterone
D. Leuteinizing hormone/follicle-stimulating hormone
E. Prolactin
101. A 17-year-old woman comes to your office complaining of increased hair growth
over the past 6 months, requiring her to wax her upper lip and chin. Her menses have
been irregular. Laboratory testing suggests she has PCOS. What is the best
recommendation for treating excess hair growth?
A. Combined hormonal contraceptive
B. Combined hormonal contraceptive and electrolysis
C. Antiandrogen and laser or electrolysis
D. Metformin and laser or electrolysis
E. Combined hormonal contraceptive, antiandrogen, and laser or electrolysis

102. An obese 38-year-old woman comes into your office complaining of several
episodes of irregular vaginal spotting throughout the past 6 months. She has a long
history of irregular periods and was diagnosed with PCOS as a teenager. She is not
sexually active and has never been on hormonal contraception. She does not desire
fertility at this time. The most important test to perform in this patient is:
A. 2-hour glucose tolerance test
B. Glucose/insulin ratio
C. Serum lipids
D. Endometrial biopsy
E. Pelvic ultrasound

103. A 27-year-old obese nulliparous woman has been on oral contraceptives since age
16 for irregular periods. She comes to your office because she stopped taking her pill
6 months prior but has not had a period since stopping her pill. She and her husband
would like to conceive, but she is worried that her weight may be a problem. You
counsel her that:
A. Her weight is not a problem
B. If she lost weight, she may start to have periods on her own
C. If she takes metformin, she will lose weight
D. Obesity is a problem and you would recommend gastric bypass
E. A 25% weight reduction is necessary to improve insulin resistance

104. A 32-year-old female, gravida 0, presents with her husband because they want to
conceive. She has PCOS diagnosed by you 14 years ago and has been maintained on
oral contraceptives and antiandrogens since then. She stopped those medications and
started prenatal vitamins as per your instructions 4 months ago and has not had a
period since. Her pregnancy test is negative. At this point you would recommend
which one of the following approaches to help her achieve a pregnancy?
A. Medroxyprogesterone acetate
B. Clomiphene citrate
C. Metformin
D. Gonadotropins (FSH LH)
E. In vitro fertilization (IVF)

Hirsutism

105. A 33-year-old woman, gravida 2, para 1, spontaneous abortions 1, presents to your

office reporting increasing dark hair growth on her chin, upper lip, and lower
abdomen. This growth has occurred over many years and has forced her to wax and
bleach more often. She denies changes in her voice or size of her clitoris, reduction in
breast size, or acne. During her early teen years, she had regular menstrual periods
that lasted 4 to 5 days. Now, however, she has to take birth control pills to regulate
her cycles. Her past medical history is significant for hepatitis C, which she acquired
 from a blood transfusion to treat postpartum hemorrhage with her first pregnancy.
The next best step in the management of hirsutism in this patient is:
A. Depomedroxyprogesterone acetate
B. Flutamide
C. Spironolactone
D. Dexamethasone
E. Leuprolide

106. A 23-year-old woman, gravida 1, para 0, abortion 1, has irregular, unpredictable

menstrual periods every 30 to 90 days. Physical examination reveals acne on her face
and back and several dark, coarse hairs on her chin and lower abdomen. The initial
step in diagnosis of androgen excess in this woman is to measure which of the
following?
A. Androstenedione
B. Dehydroepiandrosterone sulfate
C. LHandFSH
D. 17-Hydroxyprogesterone
E. 5α-Reductase

107. A 22-year-old African-American female presents to your office complaining of

severe hirsutism on her face. She is currently shaving daily and is very distressed.
After you evaluate her you diagnose PCOS. You give her what advice for the best
way to manage her hirsutism symptoms?
A. Shaving is bad because it makes the hair grow faster
B. She would be a good candidate for laser epilation
C. Medroxyprogesterone acetate is the best option
D. Combined hormonal contraception with spironolactone is the best option
E. Metformin therapy for PCOS is the best option
Abnormal Uterine Bleeding

108. A 50-year-old woman, gravida 3, para 2, spontaneous abortions 1, presents to you

reporting abnormal vaginal bleeding. Her menstrual cycles used to occur regularly
every 30 days and lasted 3 to 4 days. She now has periods every 15 to 22 days and
they last for 6 to 7 days for the last 6 months. She denies any past medical or surgical
history. Review of systems is negative and she specifically denies light -headedness.
Her speculum examination is unremarkable. The bimanual examination reveals a
slightly enlarged, regular contour, anteverted uterus that is nontender to palpation.
The next best step in management is:
A. Low-dose oral contraceptive pills
B. Endometrial biopsy
C. Dilation and curettage
D. Endometrial ablation
E. Levonorgestrel IUD

109. A 14-year-old nulligravid girl reports menstrual bleeding every 45 to 50 days and
bleeding for 4 days. She experienced menarche at age 13. She is not sexually active.
Her physical examination is unremarkable, and her serum pregnancy test is negative.
The next best step in management is:
A. Low-dose birth control pills
B. Reassurance
C. NSAIDs
D. Hysteroscopy and dilation and curettage
E. Coagulation profile

110. A 32-year-old woman, gravida 1, para 1, presents to you reporting bleeding between
her periods and lengthening of the time between her periods to more than 40 days.
Review of systems is remarkable for a 70-lb weight gain since her pregnancy 2 years
ago. She denies any medical problems. She is 5 feet 4 inches tall and weighs 230 lb.
Her physical examination is otherwise unremarkable. The most likely explanation for
her bleeding is:
A. Increased endogenous progesterone
B. Increased exogenous progesterone
C. Increased endogenous estrogen
D. Increased exogenous estrogen
E. Increased prolactin

111. An 18-year-old nulligravid girl presents to the emergency department by ambulance

because she passed out on the floor of her house and is covered in blood. She is now
conscious. She has been bleeding off and on for the past 5 months. Her BP = 98/48, P
= 120, RR = 16, and T = 96.2. Her speculum examination reveals blood trickling
from the cervical os. There are no lesions in the vagina or cervix. The bimanual
examination is unremarkable. Pelvic ultrasound is also unremarkable. Serum human
chorionic gonadotropin (hCG) is negative, and her hemoglobin is 7 g/dL. The next
best step in management of this patient is:
A. Depot-medroxyprogesterone acetate
B. Oral conjugated estrogen
C. Intravenous estrogen
D. Low-dose combination oral contraceptive pills
E. GnRH agonist therapy

112. A 38-year-old woman presents complaining of a 2-year history of heavy menstrual

flow lasting 9 days, with occasional episodes of soaking her clothes and bedsheets
with menstrual blood. Her menses are occurring every 32 days. She denies any
bleeding between menses. The rest of her history is notable for hypertension
controlled with a diuretic. The next step in evaluation would be:
A. Obtain a coagulation profile
B. Obtain a pregnancy test
C. Perform an endometrial biopsy
D. Obtain a pelvic ultrasound
E. Obtain a TSH level

Uterine Leiomyomas

113. A 25-year-old woman, gravida 4, para 4, with a history of leiomyomas, presents to

the emergency department reporting pelvic pressure. She denies cardiac, renal, or
hepatic symptoms. A pelvic ultrasound shows a 10-cm left uterine mass that has the
echogenicity of a fibroid. Pressure from the fibroid may also cause:
A. Leg ulcers
B. Peau d'orange
C. Superficial thrombophlebitis
D. Deep venous thrombosis of the leg
E. Varicose veins

114. A 30-year-old woman, gravida 2, para 2, presents to you for her annual gynecologic
visit. Currently, she has no symptoms. You perform a Pap smear and a pelvic
examination that reveals an enlarged, non-tender, irregular uterus and no adnexal
mass or tenderness. There are no vulvar or vaginal lesions. The most likely type of
fibroid is a(n):
A. Anterior intramural fibroid (5-cm size)
B. Submucosal pedunculated fibroid (2-cm size)
C. Subserosal pedunculated fibroid (7-cm size)
D. Posterior intramural fibroid (5-cm size)
E. Intramural fibroid with a submucous component (5-cm size)

115. A 22-year-old woman, gravida 2, para 1, at 20 weeks of gestation, presents to the

emergency department reporting acute-onset lower abdominal pain. She has a history
of fibroids and an unknown abdominal surgery. Her vital signs are as follows: T =
99.2, BP = 105/68, P= 110, R = 28. There is a linear, 4-cm scar in the right lower
quadrant, bowel sounds are present, and the abdomen is nontender except for spot
tenderness in the midline, between the umbilicus and the symphysis pubis. There is
no rebound tenderness or guarding. There is no costovertebral angle tenderness. Her
fundus is 28 cm above the symphysis pubis. Her white blood cells are elevated,
urinalysis is normal, and her liver function tests are within normal range. The most
likely diagnosis is:
A. Leiomyomatous degeneration
B. Ovarian torsion
C. Cystitis
 D. Preeclampsia
E. Appendicitis

116. A 27-year-old woman, gravida 2, para 1, at 30 weeks of gestation, presents to the

clinic for a routine prenatal visit. Her pregnancy has been unremarkable thus far.
“Serosal fibroids” are listed under her “problem list.” Her fundus
measures 37 cm from the symphysis pubis. In discussing possible complications of a
fibroid uterus during pregnancy, you mention that she is at highest risk for:
A. Preterm premature rupture of membranes (PROM)
B. Placenta previa
C. Pregnancy-induced hypertension (PIH)
D. Breech presentation
E. Placental abruption

117. A 49-year-old woman, gravida 3, para 2, spontaneous abortions 1, who has a known
myomatous uterus presents to you because of heavy bleeding during her periods and
occasional spotting in between her periods. Her menses occurs every 5 to 6 weeks
and lasts 6 to 10 days. It is associated with painful cramps. She has no chronic
medical problems. The next best step in management of this patient is:
A. GnRH agonist for 3 months
B. GnRH agonist for 6 months and add-back hormones for the last 3 months
C. Hysterectomy
D. Endometrial biopsy
E. Transvaginal ultrasound

Endometriosis

118. A 34-year-old woman, gravida 0, has been trying to get pregnant for the last 3 years
and has been unsuccessful. Her history is also significant for pelvic pain for several
years and deep dyspareunia. On pelvic examination, you palpate a nodular, tender
uterosacral ligament, a retroverted but normal-sized uterus, and a right adnexal mass.
A recent pelvic ultrasound reveals a 6-cm right complex ovarian mass. Her CA-125 is
elevated. What is the initial next step in management?
A. Expectant management
B. GnRH agonist
C. Diagnostic laparoscopy
D. Laparoscopy with cystectomy
E. Laparoscopy and right oophorectomy

119. A 23-year-old woman, gravida 1, para 1, reports lower abdominal pain of 1 year's
duration. She says that the pain is constant and dull and is worse around the time of
her periods. She has no significant medical history and is taking birth control pills for
contraception. You perform a laparoscopy and find several deep, typical
endometriotic lesions over the bladder and on both uterosacral ligaments and adjacent
to both ovaries. All visible lesions are ablated using the laser. What is the next best
step in management?
A. Oral contraceptive therapy
B. GnRH agonist
C. Aromatase inhibitor added to oral contraceptive therapy
D. Total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)
E. Danazol
120. Which of the following patients is unlikely to have endometriosis?
A. A 19-year-old with cyclic pelvic pain and bicornuate uterus with a noncommunicating
uterine horn
B. A 28-year-old patient with cyclic pelvic pain and who has a mother and a sister with
endometriosis
C. A 25-year-old female with a history of dyspareunia, painful nodular masses in the
rectovaginal septum, and a left adnexal mass
D. A 28-year-old with menorrhagia and a 4-cm submucosal myoma
E. A 32-year-old with infertility and dysmenorrhea and a fixed and retroverted uterus on
physical examination

Pelvic Pain

121. A 32-year-old woman, gravida 2, para 2, presents to your clinic reporting chronic
abdominal and pelvic pain. The pain is intermittent, 6/10 intensity, worse when she
lies on her left side, and nonradiating, and occurs at different times throughout her
menstrual cycle. Her past medical history is uneventful other than an appendectomy 4
years ago for a ruptured appendicitis. On physical examination of the abdomen in the
supine position, you note a small linear scar in the right lower quadrant and active
bowel sounds. The abdomen is diffusely tender to palpation, especially in the lower
quadrants, and you do not palpate any masses. Her pelvic examination is
unremarkable. The most likely diagnosis is:
A. Torsion of ovarian cyst
B. Mittelschmerz
C. Adhesive disease
D. J Psychogenic cause
E. Pelvic inflammatory disease
122. A 19-year-old female, gravida 0, has had increasingly severe menstrual cramps since
menarche. Her pain is worse around the time of her menses, but she also complains of
dyspareunia, and the pain is worse with movement. She denies any nausea or
vomiting, diarrhea, or constipation. She is otherwise healthy and denies any prior
surgery. The cause of her pelvic pain is most likely to be:
A. Gastrointestinal
B. Gynecologic
C. Gynecologic or urologic
D. Urologic
E. Gynecologic, urologic, or musculoskeletal

123. An 18-year-old nulligravid woman presents to your office because she has painful
periods. She says she only has pain during the first 2 days of her periods, which are
regular. The pain is always midline and 2 cm below the level of the umbilicus. She
says Motrin helps ease the pain. She has no other medical or surgical history. Her
pain is transmitted via:
A. Sympathetic fibers to T10
B. Sympathetic fibers to T11
C. Parasympathetic fibers to S1
D. Parasympathetic fibers to L1
E. Pudendal nerve to S2 to S4
124. A 33-year-old woman, gravida 5, para 4, therapeutic abortion (TAB) 1, presents to
the clinic with left lower quadrant pain for 2 days. She describes the pain as
intermittent initially but now constant, 7/10 intensity, nonradiating, and not associated
with any other symptoms. Her last menstrual period was 2 months ago. She had a
tubal ligation 3 years ago and a cholecystectomy 7 years ago. Her physical
examination is as follows: T = 98.5, BP = 118/76, P = 89, R = 18. Abdominal
examination reveals a scar on the right upper quadrant and a small scar within the
umbilicus and right lower quadrant, present bowel sounds, slight tenderness to
palpation in the left lower quadrant, but no rebound tenderness and no guarding. Her
pelvic examination reveals a uterus of normal size, shape, and contour, and no
adnexal masses are appreciated. What is the next best step in management?
A. Laparoscopy
B. Laparotomy
C. Antibiotics
D. Naproxen
E. Serum β-human chorionic gonadotropin (β-hCG)

125. A 25-year-old woman, gravida 4, para 3, spontaneous abortions 1, presents to your

clinic for the first time reporting pelvic pain. She has had this pain for the last 10
years and has seen several physicians. She describes the pain as continuous and dull
(4/10 intensity) with intermittent exacerbations (10/10). The pain occasionally
radiates to her lower back and down her thighs. Nothing she takes or does seems to
help her. The pain is not related to her menstrual cycle, which occurs only a few times
a year. She has dyspareunia. She has a past medical history significant for asthma,
peptic ulcer disease, and major depression. She has had a postpartum bilateral tubal
ligation. She has had three hospitalizations within the last 10 years for suicide
attempts. She also has a history of sexual abuse by a close family relative that
 occurred when she was 13 years old. Currently, she is using an albuterol metered dose
inhaler, a histamine receptor blocker, and a selective serotonin reuptake inhibitor
(SSRI). On pelvic examination, the cervix and uterus are midposition and normal in
size and consistency, but there is diffuse pain in all areas of the pelvis, especially the
right posterior cul-de-sac. The most likely cause of her pain is:
A. Endometriosis
B. Uterine fibroids
C. Mittelschmerz
D. Pelvic adhesions
E. Psychogenic cause

Ectopic Pregnancy

126. A 25-year-old woman, G1, P0, is in the emergency room complaining of lower
pelvic pain and spotting for the past week. Her last normal menstrual period was 7
weeks ago. You have obtained a serum β-hCG, which was 4000 IU/L, and a
transvaginal ultrasound was performed, which revealed no gestαtional sac in the
endometrial cavity, no adnexal masses, and no free fluid in the cul-de-sac. The next
best step in the management of this patient is:
A. Repeat β-hCG in 2 days
B. Laparoscopy
C. Laparotomy
D. Methotrexate, single-dose therapy
E. Dilation and curettage

127. A 28-year-old woman, gravida 2, para 1, ectopic 1, presents to your clinic for an
annual examination. She and her partner would like to try to have another child. Her
 menstrual cycles are regular, occurring every 28 days. You tell her that it is very
important for her to give you a call or to come back to the clinic if she misses her
period. The reason for this advice is:
A. Given her history, she has a 33% chance of delivering a live infant
B. She needs a urine pregnancy test to rule out another ectopic
C. Her risk of a recurrent ectopic is approximately 15%
D. Her risk of a recurrent ectopic is approximately 30%
E. She is at increased risk for pelvic inflammatory disease

128. A 23-year-old woman, gravida 3, para 1, ectopic 1, presents to your office because
she missed her last period and has felt a sharp, intermittent pain in her left lower
abdomen. She has no past medical history other than a left-sided ectopic pregnancy a
few years ago successfully treated with methotrexate, several years after vaginal
delivery of her only son. Her serum β-hCG level is 10,500. On physical examination,
her BP = 110/74, P = 90, and T = 97.8. She is obese and lacks peritoneal signs, and
no masses are appreciated. A transvaginal ultrasound performed in your office reveals
no gestational sac in the uterus and a 4.3-cm mass in the left adnexa separate from the
ovary. What is the next best step in management of this patient?
A. Laparoscopic salpingostomy
B. Laparoscopic salpingectomy
C. Methotrexate
D. Exploratory laparotomy
E. Repeat β-hCG in 2 days

129. A 36-year-old nulligravid woman is seeing you for her annual gynecologic care. She
has a past medical history significant for pulmonary fibrosis. Within the past 3 years,
all of the following are remarkable in her chart: bacterial vaginosis, Candida, chronic
endometritis, pyelonephritis, history of IUD that was removed 5 years ago, and
history of infertility for which she was treated with fertility drugs and in vitro
 fertilization. She is a nonsmoker but does admit to drinking two to three alcoholic
beverages every day. She has a family history significant for colon cancer in her
maternal aunt. Which of the following places her at greatest risk for an ectopic
pregnancy?
A. Age
B. Pulmonary fibrosis
C. Past IUD use
D. Infertility
E. Chronic endometritis

130. A 24-year-old woman, gravida 3, para 1, spontaneous abortions 1, presents to the

emergency room reporting irregular vaginal bleeding. She is found to be pregnant and
her serum hCG is 3500 mIU/mL. She has a past medical history significant for
diabetes mellitus and mild asthma. Her BP = 103/68, P = 88, and T = 98.8.
Transvaginal ultrasound reveals a uterus with no gestational sac present and a 2-cm
right adnexal mass. The least invasive treatment of choice is:
A. Expectant management
B. Methotrexate
C. Laparoscopic salpingostomy
D. Laparoscopic salpingectomy
E. Laparotomy

The Infertile Couple

131. Among 100 healthy, fertile couples, approximately how many will become pregnant
within 1 month if they have regular intercourse?
A. 15
B. 20
C. 35
D. 45
E. 85

132. A 26-year-old nulligravid and her 26-year-old husband are seeing you because they
have not been able to get pregnant for the last 3 years. The woman has regular periods
every 30 days that last 4 days. Both of them have no medical problems or past
surgical history. Both deny smoking, caffeine use, herbal remedy use, alcohol abuse,
or drug use. The husband's sperm analysis reveals a volume of 2.5 mL, total count
less than 0.1 × 106 sperm/mL, 10% forward progression, and 30% normal
morphology. The next best step in management of this couple is:
A. Semen wash, intrauterine insemination (IUI) with clomiphene citrate
B. IVF with ICSI and embryo transfer (ET)
C. Conventional IVF and ET (IVF-ET)
D. Karyotype, FSH, testosterone, Y microdeletion testing

Recurrent Pregnancy Loss

133. A patient with a history of three miscarriages presents to your office. The only
workup she has had done so far was a lab evaluation that showed the following
results: lupus anticoagulant screen negative, anticardiolipin IgA high positive, IgG
low positive, and IgM normal. What would you offer the patient next?
A. Discuss with her that she has antiphospholipid syndrome and devise a treatment plan
based on this diagnosis
B. Repeat antiphospholipid screen in 6 to 8 weeks
C. Start heparin and baby aspirin treatments immediately
D. Start baby aspirin with next pregnancy
E. None of the above
134. A couple with RPL gets karyotype analysis and the male partner is found to have a
robertsonian translocation involving chromosomes 14 and 21. The female partner is
normal. The next most appropriate step in the treatment of this couple is:
A. Offer IVF as an option for treatment
B. Discuss the role of donor gametes in treatment
C. Offer the couple in vitro fertilization with preimplantation genetic diagnosis (PGD)
D. Close observation with next pregnancy
E. Send the couple for a consult with a genetic counselor

135. A patient with a history of three miscarriages presents to your office. The only
workup she has had done so far was a lab evaluation that showed the following
results: lupus anticoagulant screen negative, anticardiolipin IgG high positive, and
IgM normal. What would you offer the patient next?
A. Discuss with her that she has antiphospholipid syndrome and devise a treatment
plan based on this diagnosis
B. Repeat antiphospholipid screen in 6 to 8 weeks
C. Order a hysterosalpingogram
D. B and C
E. None of the above

Pediatric and Adolescent Gynecology

136. A 15-year-old female is brought to your office complaining of severe dysmenorrhea

that has become progressively worse since the onset of menses. Menarche occurred at
age 13. The pain is located predominantly on the right side, lasts for the duration of
the menstrual flow, and at its worst is associated with nausea and vomiting. She has
had to miss school with every menstrual period for the past year. She has tried
 nonsteroidal medications, which initially helped but no longer relieve the pain
significantly. The next step in management is:
A. Take the maximal dose of nonsteroidal medications and see if pain is improved
B. Refer her to psychiatry since this may just be a ploy to get out of school
C. Start combined oral contraceptive hormone pills
D. Obtain a pelvic ultrasound
E. Perform a laparoscopy to evaluate for endometriosis

137. An 8-year-old girl is brought to your office by her mother because of occasionally
bloody vaginal discharge. Her mother suspects sexual abuse because she doesn't
“know of any other reason why a little girl should be bleeding from her vagina.”
She has no other medical history except for a throat infection a few weeks ago, which
was treated with penicillin. On physical examination, she has enlargement of both
breasts and enlarged areolae. There is no axillary hair growth. No pubic hair is
apparent. The external genitalia have an age-appropriate clitoris and normal labia
minora. There are no bruises, hematomas, or lacerations. You take a culture of the
 vaginal discharge, which is pink to red colored and not foul smelling. You are not
able to perform a more through examination. The most likely cause of her vaginal
bleeding is:
A. Precocious puberty
B. Sexual abuse
C. Foreign body
D. Bacterial infection
E. Pinworm

138. A 6-year-old girl is brought to your office because she has had four urinary tract
infections within the last 3 months. While the mother is holding her, you examine her
genitalia. There is lack of pubic hair. The labia minora are in apposition but are easily
separable with gentle traction. You note a 1-cm sized clitoris. There is a 0.3-cm cystic
structure in the inferior aspect of the urethra, which is nontender to cotton swab
palpation; however, it has left a red hue on your cotton swab. You order a urinalysis
and a urine culture and sensitivity. The safest and next best step in management is:
A. Estrogen cream
B. Sitz baths
C. Intravenous pyelography
D. Low-potency steroid cream
E. Surgical repair

139. A 24-year-old woman, gravida 1, para 1, just delivered a live female infant by
natural birth. The infant weighed 3990 g and had APGARs of 8 and 9 at 1 and 5
minutes, respectively. Upon inspection of the neonate, the pediatricians are unable to
assign a gender because there is clitoral hypertrophy and the labia majora are partially
fused. You do not palpate any masses within them. The most important next step in
management of this condition is:
A. 17-OH-progesterone level
B. Dehydroepiandrosterone level
C. Serum sodium level
D. Tell the parents they have a baby girl
E. Karyotype

140. You are a world-renowned reproductive endocrinologist and are asked to make a
diagnosis for a patient who has ambiguous genitalia. Here are the data:
Karyotype XY
Spermatogenesis Absent
Müllerian structureAbsent
Wolffian structures Present
External genitalia Male hypospadias
Breast Gynecomastia
The diagnosis is:
A. True hermaphroditism
B. Mixed gonadal dysgenesis
C. Swyer syndrome
D. Complete androgen insensitivity
E. Reifenstein syndrome

Menopause

141. A 50-year-old woman has menses every 2 to 3 months and hot flashes that wake her.
She falls asleep in the afternoon at work because she doesn't sleep well at night. She
is otherwise healthy and has no medical risk factors. She asks you if she is at risk for
becoming pregnant with unprotected intercourse and wants your advice regarding
managing her symptoms. You should:
A. Check FSH levels
 B. Advise her that she is too old to possibly conceive
C. Advise her to use natural family planning for reliable protection against becoming
pregnant
D. Discuss using a low-dose combination hormonal contraceptive with her
E. Recommend she have a tubal ligation

142. A healthy 35-year-old woman, G2P2, presents with a history of regular menses since
age 14, until her last period 1 year ago. Her human chorionic gonadotropin (hCG) is
negative, serum estradiol less than 20 pg/mL, FSH and LH greater than 100 mIU/mL,
and prolactin less than 20 ng/mL. She has hot flashes and dyspareunia that disrupt her
life. Which of the following is NOT true?

A. The patient is at an increased risk of bone loss and fracture compared to

menstruating women her age
B. The patient has premature ovarian failure and should be offered HT both for her
symptoms and to protect her from bone loss
C. This is a typical menopausal woman
D. This patient should receive progestogen in addition to estrogen if she chooses to
take systemic hormones
E. Vaginal estrogens will relieve her genitourinary symptoms

143. Current studies regarding the risks and benefits of HT/ET put perimenopausal and
menopausal women in a treatment dilemma. Which of the following is true?

A. Women using HT have twice the risk of developing breast cancer compared to healthy
menopausal women
B. HT prevents all-cause dementia in women who begin medication after the age of 65
years
C. HT/ET should be given in the lowest doses for the shortest duration of time needed to
achieve the desired effect
D. If a woman with breast cancer has symptoms due to chemotherapy-induced
menopause, she has no available pharmacologic agents available to her
E. HT/ET is indicated for prevention of skin changes due to estrogen deficiency and for
prevention of cardiovascular disease

144. A frail 70-year-old woman with her FMP at age 51 complains of back pain and a 4-
inch loss in height. Spine films confirm the presence of multiple osteoporosis-related
vertebral compression fractures. Her DEXA hip T score = -2.7. Your concerns for
management include all but which of the following?
A. Potential risk of future hip fracture
B. Assessment of risk of falling
C. Concern that the patient's positive smoking history will exclude her from therapy to
prevent future fractures
D. Concern that a SERM may not be as effective as a bisphosphonate in treating this
patient
E. Concern that the patient's immobility may limit her ability to perform weight-bearing
exercise or go outside for sun exposure to increase endogenous vitamin D

145. A 55-year-old woman with her FMP at age 50 presents with a history of 3 days of
light vaginal bleeding. You should:
A. Give her vaginal estrogen for atrophic vaginitis and tell her to come back if the
bleeding doesn't get better
B. Perform a hysterectomy and bilateral salpingo-oophorectomy to rule out endometrial
cancer
C. Take a history, perform a physical examination, perform endometrial tissue sampling,
and order a pelvic ultrasound or perform hysteroscopy
D. Recommend she go on a diet, since there is increased production of estrone in obese
women
E. Start ET instead of HT, since adding a progestogen may make her bleed

Family Planning: Contraception and Complications

146. Your 24-year-old multiparous patient is interested in long-term contraception, but is

concerned that the copper IUD acts as an abortifacient. The best guidance you could
give her is:
A. She should not use the copper IUD because its main mechanism of action is as an
abortifacient
B. The main way in which the copper IUD prevents pregnancy is by acting as a
spermicide
C. Tubal ligation is a more effective long-term contraceptive than an IUD, so she
should consider that instead
D. IUD is associated with a high rate of infection (pelvic inflammatory disease)

147. A 25-year-old woman, gravida 1, para 0, therapeutic abortions (TAB) 1, presents to

the emergency department and is being evaluated for date rape, which occurred 12
hours ago. She says that the rapist forced himself onto her and had time to ejaculate
inside her. She has no past medical history. In addition to prophylactic treatment for
STDs, complete rape evaluation, and counseling, the most effective and widely
available management to prevent pregnancy is:
A. Ethinyl estradiol and norgestrel, two tablets now and two in 12 hours
B. Ethinyl estradiol and norgestrel, two tablets now and two in 12 hours, and
prochlorperazine
C. Plan B 150 mg now
D. Levonorgestrel, 0.75 mg now and another in 12 hours
E. Mifepristone (RU-486)

Sexually Transmitted Diseases

148. A 22-year-old nulligravid woman presents to you because of a 5-day history of

frequent urination and dysuria. She was seen by a doctor 2 days ago and prescribed
ampicillin. She has no remarkable medical history. She is sexually active and recently
began having intercourse with a new boyfriend. She has no known drug allergies.
Today her urinalysis shows the following: 2 squamous cells, 0 nitrites, 18 WBC/hpf,
0 bacteria. Her urine human chorionic gonadotropin (hCG) is negative. The next best
step in management is:
A. Ceftriaxone
B. Trimethoprim-sulfamethoxazole
C. Spectinomycin
D. Azithromycin
E. Observation

149. A 26-year-old woman, gravida 1, para 0, at 14 weeks of gestation, presents to you

because of increased vaginal discharge. You perform a wet mount and test for
gonorrhea and chlamydia by NAAT. The results of NAAT are positive for chlamydia.
The next step in management is (note: TOC = test of cure and RS = rescreen):
A. Azithromycin (patient and partner) + TOC 5 weeks + RS 4 months
B. Doxycycline (patient and partner) + TOC 5 weeks + RS 5 months
C. Ofloxacin (patient and partner) + TOC 4 weeks + RS 4 months
D. Erythromycin (patient and partner) + TOC 3 weeks + RS 4 months
E. Erythromycin (patient and partner) + TOC 2 weeks + RS 3 months
150. A 20-year-old presents to you with a deep, excavating, painless lesion above the
clitoris, overlying the pubic bone. Her serum VDRL is positive. A lumbar puncture
and analysis of her cerebrospinal fluid also yields a positive VDRL. The best term to
describe her lesion is:
A. Condyloma acuminatum
B. Condyloma latum
C. Chancre
D. Gumma
E. Bubo

151. A 17-year-old adolescent presents to your office reporting intense itching “down
there.” You perform a wet mount and KOH prep but are unable to find anything
remarkable. Examination of her pubic hair in the area of the mons with a hand lens
reveals several linear lesions and adjacent erythema from self-scratching. Her
pregnancy test is negative. The next best step in management is neck-down treatment
with:
A. Permethrin 1% for 10 hours + clean toilet seats
B. Permethrin 5% for 10 hours + wash bed sheets
C. Permethrin 5% for 10 minutes + clean toilet seats
D. Lindane 1% for 4 minutes + wash clothing
E. Lindane 1% for 8 hours + wash bed sheets

Pelvic Inflammatory Disease

152. A 19-year-old woman, whose last menstrual period (LMP) was 32 days ago and who
is sexually active, presents to the emergency department reporting a 5-day history of
lower abdominal pain. Her vitals are as follows: T = 101°F, BP = 110/75, P = 80, R
= 16. Speculum examination reveals purulent exudate at the cervical os, and there is
cervical motion tenderness. Bimanual examination is unremarkable for masses but
 produces severe discomfort. Her quantitative serum hCG =150 mIU/mL. Urinalysis is
normal. Her WBC count is 14,000. An office ultrasound shows a normal-sized,
normal-striped uterus and no adnexal masses. The next best step in management of
this patient is:
A. Repeat serum hCG in 48 hours
B. Penicillin G intravenously
C. Ampicillin and gentamicin intravenously
D. Clindamycin and gentamicin intravenously
E. Cefazolin and doxycycline intravenously

153. The most important reason that PID must be recognized and treated promptly is
prevention of:
A. Pelvic pain syndrome
B. Infertility
C. Ectopic pregnancy
D. Tubo-ovarian abscess
E. Pelvic adhesive disease

154. A 17-year-old woman has symptoms suggestive of pelvic inflammatory disease.

However, the patient is adamant that she is a virgin. If the signs of PID are present
because of inflammation involving the uterus, tubes, and ovaries, the most likely
diagnosis is:
A. Tuberculosis
B. Endomyometritis
C. Schistosomiasis
D. Appendicitis
E. Ectopic pregnancy
Intimate Partner Violence and Sexual Assault

155. A married, 26-year-old woman, gravida 4, para 3, at 30 weeks of gestation, presents

to you for routine prenatal care. Her medical history is remarkable for active hepatitis
B and moderate asthma. She had an appendectomy 4 years ago. She has no known
drug allergies. All of her prenatal labs are in order. Upon measuring her fundus, you
notice several bruises in the shape of a long cylindric object on her shins and thighs.
What is the best opening question to address relationship violence?
A. When did your husband beat you?
B. Did your husband use a broomstick to beat you?
C. Are you afraid of your husband?
D. Is your husband physically abusing you with different objects around the house?
E. Is your relationship with your husband one that makes you want to hide from him?

156. A 27-year-old woman, gravida 3, para 2, spontaneous abortions 1, has been beaten
many times by her husband. She wants help, but she has not told anyone about what
has been happening. The most likely reason that she has not told the physician is:
A. She does not want to talk about the issue
B. She is afraid of breaking up her family
C. It is not a medical problem
D. She is afraid of retaliation by the partner, especially on the children
E. She has deep-rooted masochistic tendencies
157 A woman discloses to her physician that her husband beats her when he is drunk and
that she is afraid of him. The physician's main role is to:
A. Help the patient understand why she must leave the relationship immediately
B. Accept that this is a personal issue and not interfere
C. Report the abuse to the National Center for Injury Prevention and Control
D. Involve a social worker
E. Focus on patient safety issues, such as exit plans and copies of important documents

158. Intimate partner violence significantly increases in incidence:

A. After the first year of marriage
B. Shortly after the birth of an infant
C. After one partner retires
D. After a couple's children have left the home
E. In a household where one partner is a homemaker and the other the provider

Benign Breast Disease

159. A 36-year-old woman, gravida 4, para 4, presents to your clinic because she has had
bilateral white-colored nipple discharge for the last 3 months. She breastfed her last
baby, but that ended almost 2 years ago. She has no past medical history other than
depression, for which she takes a tricyclic anti-depressant. She is married and uses
birth control pills for contraception. She has no known drug allergies. Examination of
the breasts reveals no discrete masses. When the nipple discharge is placed on a slide
and viewed under a light microscope, fat globules are seen that are reminiscent of
milk. Which of the following is the next best step in management?
A. Obtain a prolactin level
B. Schedule a follow-up in 6 weeks
C. Collect discharge for cytopathology
D. Discontinue antidepressant
E. Substitute nonhormonal method of contraception

160. A 30-year-old woman, gravida 2, para 2, presents to your office reporting a mass in
her right breast that she just noticed on breast self-examination. She has no medical
problems. There is no history of breast or ovarian cancer in her family. Her
examination is notable for a 2-cm mass in her right breast that is smooth, mobile, and
nontender. Your next step is:
A. Reassure her that the mass is benign
B. Recommend vitamin E
C. Obtain an ultrasound of the mass
D. Refer her to a breast surgeon for excision of the mass
E. Recommend a mammogram

161. A 60-year-old woman, gravida 3, para 2, spontaneous abortions 1, presents to your

clinic reporting brownish red-colored discharge from her left nipple. Her past medical
history and medications, respectively, are as follows: diabetes, oral hypoglycemic;
hypertension, angiotensin-converting enzyme inhibitor; and major depression,
fluoxetine. She is also taking conjugated estrogen with medroxypro-gesterone acetate
daily. She is allergic to penicillin. She says her mother was diagnosed with ovarian
cancer at age 71. What is the next best step in management?
A. Mammogram
B. Fine needle aspiration (FNA)
C. Referral to breast surgeon
D. Cessation of hormone replacement therapy
E. Ultrasound
162. A 28-year-old woman, gravida 2, para 2, who delivered a healthy female infant 10
days ago, comes to labor and delivery because of a tender breast mass on the right.
She is breastfeeding exclusively. On examination of her breasts you note bilateral
mild engorgement of the breasts and a tender, firm, linear, and slightly erythematous
cord in the lateral aspect of her right breast. What is the next best step in
management?
A. Observation
B. Heat compresses
C. Mammogram
D. Biopsy
E. Dicloxacillin

Vulvovaginitis

163. A 23-year-old woman, gravida 2, para 1, at 10 weeks of gestation, presents to your

office and reports increasing yellow vaginal discharge that has an odor. A vaginal
smear reveals clue cells. She denies pruritus. She does not have any significant
medical history or allergies to medication. The next step in management of this
patient is:
A. Oral metronidazole
B. Vaginal metronidazole
C. Oral clindamycin
D. Vaginal clindamycin
E. Oral fluconazole
164. A 25-year-old woman, gravida 1, para 1, presents to your office reporting four
recurrent yeast infections within the last 2 months. You perform a wet mount and a
10% KOH prep and confirm presence of many pseudohyphae and absence of clue
cells or leukocytes. She is not pregnant, is not on birth control, and has not been
sexually active for 7 months. What is the next step in management of this patient?
A. Screen for STDs
B. Long-term oral ketoconazole
C. Boric acid capsules intravaginally
D. Screen for HIV
E. Random glucose level

Disorders of the Pelvic Floor

165. A 60-year-old woman, gravida 5, para 4, spontaneous abortions 1, has been treated
with vaginal estrogen therapy, various pelvic muscle rehabilitation therapies, and
pessaries for symptoms of pelvic prolapse without incontinence for the past 2 years.
She desires definitive therapy. She has no past medical history other than
hypertension, for which she takes hydrochlorothiazide. All of her children were
delivered vaginally. On pelvic examination, vaginal mucosa is pink and moist. The
anterior vaginal wall prolapses up to the hymenal ring on Valsalva. When the anterior
vagina is supported with half of the speculum, the uterus and cervix prolapse past the
hymenal ring as well. There is no stress incontinence when the urethrovesical
junction is supported and the cystocele reduced. The uterus is normal in size, contour,
and consistency. The sacral neurologic examination is unremarkable. A urine culture
is sent. The next best step in management of this patient is:
A. Electrical stimulation of pelvic musculature
B. Abdominal hysterectomy and anterior repair
C. Vaginal hysterectomy and anterior repair
D. Vaginal hysterectomy, anterior repair, and suburethral sling
E. Burch retropubic urethropexy and anterior repair
166. A 32-year-old woman, gravida 3, para 3, just delivered a viable female infant
weighing 4000 g via cesarean section for nonreassuring fetal heart rate pattern. She
received intrathecal (spinal) anesthetic and narcotic for pain relief during the
procedure. Her Foley catheter is left in place for several hours after the cesarean
section. This will prevent:
A. Stress incontinence
B. Urge incontinence
C. Overflow incontinence
D. Bypass incontinence
E. Postoperative urinary tract infection

167. A 56-year-old woman, gravida 2, para 2, who reports leaking urine when she coughs
and exercises, is diagnosed with genuine stress urinary incontinence. A regimen of
Kegel exercises does not improve her symptoms, and she desires more definitive
treatment. Her doctor recommends laparoscopic retropubic urethropexy. When
discussing the risks and benefits of the laparoscopic Burch procedure, the doctor
should mention:
A. Low short-term cure rates
B. 60% long-term cure rates
C. Risk of urinary retention
D. Alternative of drug therapy
E. Risk of graft infection and ulceration

168. A 67-year-old woman, gravida 3, para 3, presents to your office reporting

incontinence. She tells you that she voids almost 40 times during the day and has
several episodes of nocturia. She says she feels like voiding two to three times an
hour and that when she makes it to the bathroom, only small amounts of urine are
 voided. Her past medical history is remarkable for mild asthma, for which she takes
albuterol. Her previous gynecologist also placed her on estrogen patch, estrogen
vaginal cream, and intravaginal progesterone tablets. She had a cholecystectomy 20
years ago and she is allergic to penicillin. Her BP = 130/80 mmHg, P = 80 bpm,
height = 5 feet 4 inches, weight = 230 lb. On physical examination you notice pink,
moist vaginal epithelium with mild cystocele and well-supported proximal urethra.
The next best step in management of this patient is:
A. Urinalysis
B. Tolterodine
C. Pseudoephedrine
D. Pessary
E. Suburethral sling

169. A 55-year-old Caucasian woman, gravida 3, para 3, who delivered all of her children
by scheduled cesarean sections (prior to initiation of labor), has mild pelvic organ
prolapse. She had her last period 3 years ago and since that time has been on estrogen
patches and progesterone vaginal tablets for treatment of hot flushes and vaginal
dryness. She has no chronic medical problems but is on antibiotic therapy for acute
bronchitis. Her family history is significant for osteoporosis diagnosed at an earlier
age than average in her mother, two sisters, and grandmother. The strongest risk
factor for pelvic relaxation in this patient is:
A. Parity
B. Age
C. Hormone status
D. Genetic
E. Cough

170. HPV is associated with the development of cervical, vaginal, vulvar, and anal
cancers. Which of the following statements is true?
A. HPV types 16 and 18 are detected in over 95% of cases of cervical cancer
B. The quadrivalent vaccine that is currently approved for prevention of HPV infection is
over 95% effective in preventing HPV 16-and 18-related cervical cancers
C. By age 50,46% of women in the United States will have acquired a genital HPV
infection
D. HPV types 6 and 11 are oncogenic and therefore are most often associated with genital
warts
E. 95% of HPV infections are transient and will be cleared within 1–2 years

171. A 40-year-old woman, gravida 1, para 1, presents to you because she wants to
decrease her risk of ovarian cancer via a prophylactic oophorectomy. She has no
chronic medical problems except obesity. Her gynecologic history is remarkable for
first sexual intercourse at age 15 years, four sexual partners in her entire life, and
breastfeeding of her only child. Her Pap smear has shown exposure to HPV. She had
infertility and conceived her only child with in vitro fertilization, and subsequently
was taking birth control pills. She smokes one pack per week (for the last 10 years)
and has an occasional drink with her husband. Her family history is remarkable for
breast cancer in her mother and maternal grandmother and ovarian cancer in her
maternal aunt. The most significant risk factor for developing ovarian cancer is her:
A. Family history
B. HPV
C. Low parity
D. Birth control pills
E. Smoking

172. A 23-year-old woman, gravida 1, para 0, spontaneous abortions 1, has undergone

colposcopy for evaluation of a high-grade lesion found on Pap smear. The
squamocolumnar junction was visible in its entirety, and the endocervical curettage
 was normal. A directed biopsy of the cervix revealed a 1-mm focus of invasion. The
next best step in management is:
A. Radical trachelectomy
B. Cryotherapy of cervix (Cryo)
C. Cold knife conization of cervix (CKC)
D. Simple hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO)
E. Radical hysterectomy (Rad Hyst)

173. It is important for a physician to_____________________when counseling a couple

who wishes artificial insemination.
A. Explain that divorce absolves the husband from child support
B. Explain that there is no guarantee of pregnancy if protocol is followed
C. Explain that, with screening, birth defects are not possible
D. Explain that transmission of STDs is very likely
E. Explain that a divorce excludes the husband from access to the child

174. An obstetrician is called at home by a woman who is in labor. Although she has
never been to see the obstetrician for a prenatal visit, she would like him to deliver
her infant. The obstetrician refuses to attend to her because he is in the middle of
dinner. She subsequently delivers a healthy infant at home. If this woman sues the
physician for negligence, which of the following would be his best defense?
A. Labor is not a disease, so it was not necessary to attend to this pregnant woman
B. Because the woman did not come for prenatal visits, she is not entitled to a physician
C. Because the woman gave birth to a healthy infant, no harm was done
D. The physician never accepted the woman as his patient
E. The patient was contributorily negligent in not calling the physician long in advance of
active labor
175. A gynecologist has a longstanding relationship with a patient. The woman becomes
pregnant but does not inform her gynecologist of her pregnancy and is not scheduled
to see him until the next annual visit. One Saturday she calls to report nausea and
vomiting but is unable to reach her physician, who is on vacation and has left no other
physician to take care of his patients. Three months later the patient goes into preterm
labor and delivers a premature infant. The infant ultimately dies 1 month later. In a
lawsuit, which of the following statements is the physician's best defense?
A. No physician-patient relationship existed
B. The physician did not breach any duty owed to the patient
C. The premature delivery and fetal death was unrelated to the physician's time on
vacation
D. A premature infant is not a viable human being
E. The woman has not suffered any injuries

176. A 34-year-old woman, gravida 1, para 1, delivers a boy with Tay-Sachs disease.
Eight years later, she and her husband obtain the services of a lawyer and sue the
physician, alleging that he was remiss in genetic counseling, and because of this, a
child with an irreversible neurologic disease had to be brought into the world. The
best term to describe this lawsuit is:
A. Wrongful birth
B. Wrongful conception
C. Wrongful life
D. Medical malpractice
E. Wrongful counseling