Cervical ripening methods US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Cervical ripening methods. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Cervical ripening methods US Medical PG Question 1: A 36-year-old primigravid woman at 26 weeks' gestation comes to the physician complaining of absent fetal movements for the last 2 days. Pregnancy was confirmed by ultrasonography 14 weeks earlier. She has no vaginal bleeding or discharge. She has a history of type 1 diabetes mellitus controlled with insulin. Vital signs are all within the normal limits. Pelvic examination shows a soft, 2-cm long cervix in the midline with a cervical os measuring 3 cm and a uterus consistent in size with 24 weeks' gestation. Transvaginal ultrasonography shows a fetus with no cardiac activity. Which of the following is the most appropriate next step in management?
- A. Plan for oxytocin administration (Correct Answer)
- B. Perform weekly pelvic ultrasound
- C. Perform dilation and curettage
- D. Perform cesarean delivery
- E. Administer magnesium sulfate
Cervical ripening methods Explanation: ***Plan for oxytocin administration***
- The patient is at 26 weeks' gestation with confirmed fetal demise and an effaced, dilated cervix (2 cm long, 3 cm dilated). This indicates the cervix is already preparing for delivery.
- **Oxytocin** is the most appropriate next step to induce labor and facilitate vaginal delivery in cases of **intrauterine fetal demise** (IUFD) after the first trimester, especially when cervical changes have begun.
*Perform weekly pelvic ultrasound*
- The ultrasound has already confirmed **absent fetal cardiac activity**, making repeated ultrasounds unnecessary as the diagnosis of IUFD is already established.
- This option would delay necessary management and exposure to the deceased fetus in utero could increase risks such as **coagulopathy** if prolonged.
*Perform dilation and curettage*
- **Dilation and curettage (D&C)** is generally reserved for termination of pregnancy or management of miscarriage up to **16-18 weeks' gestation**.
- At **26 weeks' gestation**, the size of the fetus and uterus makes D&C a less safe and less effective procedure compared to labor induction.
*Perform cesarean delivery*
- **Cesarean delivery** for IUFD is typically reserved for cases with maternal indications (e.g., prior classical C-section scar, placenta previa obstructing the birth canal) or when labor induction fails.
- There are no maternal or fetal contraindications to vaginal delivery in this scenario, and a C-section would primarily increase maternal morbidity without fetal benefit.
*Administer magnesium sulfate*
- **Magnesium sulfate** is used for **neuroprotection** in preterm deliveries (usually before 32 weeks) and seizure prophylaxis in **preeclampsia/eclampsia**.
- As the fetus is deceased, neuroprotection is not applicable, and there are no signs of preeclampsia, making this intervention inappropriate.
Cervical ripening methods US Medical PG Question 2: Group of 100 medical students took an end of the year exam. The mean score on the exam was 70%, with a standard deviation of 25%. The professor states that a student's score must be within the 95% confidence interval of the mean to pass the exam. Which of the following is the minimum score a student can have to pass the exam?
- A. 45%
- B. 63.75%
- C. 67.5%
- D. 20%
- E. 65% (Correct Answer)
Cervical ripening methods Explanation: ***65%***
- To find the **95% confidence interval (CI) of the mean**, we use the formula: Mean ± (Z-score × Standard Error). For a 95% CI, the Z-score is approximately **1.96**.
- The **Standard Error (SE)** is calculated as SD/√n, where n is the sample size (100 students). So, SE = 25%/√100 = 25%/10 = **2.5%**.
- The 95% CI is 70% ± (1.96 × 2.5%) = 70% ± 4.9%. The lower bound is 70% - 4.9% = **65.1%**, which rounds to **65%** as the minimum passing score.
*45%*
- This value is significantly lower than the calculated lower bound of the 95% confidence interval (approximately 65.1%).
- It would represent a score far outside the defined passing range.
*63.75%*
- This value falls below the calculated lower bound of the 95% confidence interval (approximately 65.1%).
- While close, this score would not meet the professor's criterion for passing.
*67.5%*
- This value is within the 95% confidence interval (65.1% to 74.9%) but is **not the minimum score**.
- Lower scores within the interval would still qualify as passing.
*20%*
- This score is extremely low and falls significantly outside the 95% confidence interval for a mean of 70%.
- It would indicate performance far below the defined passing threshold.
Cervical ripening methods US Medical PG Question 3: A 32-year-old nulligravid woman comes to the physician because of 2 weeks of postcoital pain and blood-tinged vaginal discharge. She has been sexually active with one male partner for the past 3 months. They do not use condoms. Her only medication is a combined oral contraceptive that she has been taking for the past 2 years. She states that she takes the medication fairly consistently, but may forget a pill 2–3 days per month. One year ago, her Pap smear was normal. She has not received the HPV vaccine. The cervix is tender to motion on bimanual exam. There is bleeding when the cervix is touched with a cotton swab during speculum exam. Which of the following is the most likely diagnosis?
- A. Uterine leiomyomas
- B. Cervix trauma
- C. Chlamydia infection (Correct Answer)
- D. Early uterine pregnancy
- E. Breakthrough bleeding
Cervical ripening methods Explanation: ***Chlamydia infection***
- The presence of **postcoital pain, blood-tinged vaginal discharge, cervical motion tenderness, and friable cervix (bleeding on touch)** are classic signs of **cervicitis**, often caused by Chlamydia.
- Her new sexual partner, lack of condom use, and inconsistent oral contraceptive use increase her risk for **sexually transmitted infections (STIs)**.
*Uterine leiomyomas*
- These are benign uterine tumors that can cause **heavy menstrual bleeding**, **pelvic pressure**, and **infertility**, but typically not acute postcoital pain or blood-tinged discharge with cervical friability.
- **Submucosal fibroids** can cause abnormal bleeding, but it's usually not associated with cervical motion tenderness or friability.
*Cervix trauma*
- While trauma can cause bleeding, the description of **cervical motion tenderness** and **friability** points towards an underlying inflammatory process rather than simple trauma.
- Her symptoms have been present for **2 weeks**, suggesting an ongoing issue, not a one-time traumatic event.
*Early uterine pregnancy*
- Early pregnancy can cause some **spotting (implantation bleeding)**, but it typically does not present with significant **postcoital pain**, **cervical motion tenderness**, or profuse blood-tinged discharge.
- The use of **oral contraceptives**, even inconsistently, makes pregnancy less likely, although not impossible.
*Breakthrough bleeding*
- Breakthrough bleeding (BTB) is common with **oral contraceptive use**, especially with missed pills, but it usually presents as **irregular uterine bleeding** and not typically with **cervical motion tenderness** or a friable cervix.
- The presence of postcoital pain and cervical signs suggests an **infection** rather than just hormonal irregularities.
Cervical ripening methods US Medical PG Question 4: A 26-year-old gravida 4 para 1 presents to the emergency department with sudden severe abdominal pain and mild vaginal bleeding. Her last menstrual period was 12 weeks ago. She describes her pain as similar to uterine contractions. She has a history of 2 spontaneous abortions in the first trimester. She is not complaining of dizziness or dyspnea. On physical examination, the temperature is 36.9°C (98.4°F), the blood pressure is 120/85 mm Hg, the pulse is 95/min, and the respiratory rate is 17/min. The pelvic examination reveals mild active bleeding and an open cervical os. There are no clots. Transvaginal ultrasound reveals a fetus with no cardiac activity. She is counseled about the findings and the options are discussed. She requests to attempt medical management with mifepristone before progressing to surgical intervention. Which of the following describes the main mechanism of action for mifepristone?
- A. Interferes with cell growth in rapidly dividing cells
- B. Increase myometrial sensitivity to contractions and induce decidual breakdown (Correct Answer)
- C. Induce teratogenesis in the fetus
- D. Induce cervical dilation
- E. Interferes with placental blood supply to the fetus
Cervical ripening methods Explanation: ***Increase myometrial sensitivity to contractions and induced decidual breakdown***
- **Mifepristone** acts primarily as a **progesterone receptor antagonist**, blocking progesterone's effects.
- This blockade leads to **decidual breakdown**, increased uterine contractility, and increased sensitivity of the myometrium to prostaglandins, facilitating expulsion of uterine contents.
*Interferes with cell growth in rapidly dividing cells*
- This mechanism describes **chemotherapeutic agents** like methotrexate, which targets rapidly dividing cells.
- **Mifepristone** does not interfere with cell growth in this manner; its action is receptor-mediated.
*Induce teratogenesis in the fetus*
- While mifepristone can affect fetal development by terminating a pregnancy, its primary mechanism of action is **not directly teratogenesis** (the induction of birth defects).
- Its purpose is to induce abortion or miscarriage, not to cause malformations in a continuing pregnancy.
*Induce cervical dilation*
- While cervical dilation occurs as a consequence of the abortion process facilitated by mifepristone, it is not the **primary mechanism of action** of the drug itself.
- Cervical dilation is often secondary to uterine contractions and the release of prostaglandins, which are downstream effects of mifepristone.
*Interferes with placental blood supply to the fetus*
- **Mifepristone's** main action is not directly on the placental blood supply; rather, it affects the **uterine lining and myometrial activity**.
- The disruption of pregnancy by mifepristone leads to secondary effects on the placenta and fetal viability, but it doesn't primarily block blood flow.
Cervical ripening methods US Medical PG Question 5: A 27-year old primigravid woman at 37 weeks' gestation comes to the emergency department because of frequent contractions for 4 hours. Her pregnancy has been complicated by hyperemesis gravidarum which subsided in the second trimester. The contractions occur every 10–15 minutes and have been increasing in intensity and duration since onset. Her temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. Uterine contractions are felt on palpation. Pelvic examination shows clear fluid in the vagina. The cervix is 50% effaced and 3 cm dilated. After 4 hours the cervix is 80% effaced and 6 cm dilated. Pelvic examination is inconclusive for the position of the fetal head. The fetal heart rate is reassuring. Which of the following is the most appropriate next step?
- A. Administer oxytocin
- B. Perform external cephalic version
- C. Administer misoprostol
- D. Perform Mauriceau-Smellie-Veit maneuver
- E. Perform ultrasonography (Correct Answer)
Cervical ripening methods Explanation: ***Perform ultrasonography***
- The examination notes that the **pelvic examination is inconclusive for the position of the fetal head**, which is a critical piece of information needed for safe delivery. **Ultrasonography** is the most appropriate next step to ascertain the fetal presentation and position, especially given the dilated cervix.
- Determining fetal position is essential to rule out **malpresentation**, such as **breech** or **transverse lie**, which would significantly impact the delivery plan and potentially necessitate a **cesarean section**.
*Administer oxytocin*
- **Oxytocin** is used to induce or augment labor when contractions are insufficient or labor is prolonged, but in this case, the cervix is progressing well (from 3 cm to 6 cm dilation in 4 hours), indicating **active labor**.
- Without knowing the fetal presentation, administering oxytocin could exacerbate issues if there's a **malpresentation**, potentially leading to **fetal distress** or **uterine rupture**.
*Perform external cephalic version*
- **External cephalic version (ECV)** is performed to change a **breech presentation** to a **cephalic presentation** by external manipulation, typically done before labor onset or early in labor at term.
- This patient is already in **active labor** with significant cervical dilation (6 cm), making ECV less likely to be successful and potentially increasing risks like **placental abruption** or **umbilical cord compression**.
*Administer misoprostol*
- **Misoprostol** is a prostaglandin analog used for **cervical ripening** and **labor induction** in cases where the cervix is unfavorable or labor needs to be initiated.
- This patient is already in **active labor** with progressive cervical dilation, making misoprostol unnecessary and potentially harmful due to the risk of **uterine hyperstimulation**.
*Perform Mauriceau-Smellie-Veit maneuver*
- The **Mauriceau-Smellie-Veit maneuver** is a technique used during a **vaginal breech delivery** to deliver the fetal head, specifically in cases of **frank or complete breech** that are being delivered vaginally.
- This maneuver is only performed *during* delivery of a breech baby, and the fetal position is currently unknown. It would be premature and inappropriate to consider this maneuver without first confirming a **breech presentation** and the decision for vaginal delivery.
Cervical ripening methods US Medical PG Question 6: A 24-year-old woman, gravida 1, at 35 weeks gestation is admitted to the hospital with regular contractions and pelvic pressure for the last 5 hours. Her pregnancy has been uncomplicated and she has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. She has had no history of fluid leakage or bleeding. At the hospital, her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 16/min. Cervical examination shows 60% effacement and 5 cm dilation with intact membranes. Cardiotocography shows a contraction amplitude of 220 MVU in 10 minutes. Which of the following is the most appropriate pharmacotherapy at this time?
- A. Magnesium sulfate
- B. No pharmacotherapy at this time (Correct Answer)
- C. Dexamethasone
- D. Oxytocin
- E. Terbutaline
Cervical ripening methods Explanation: ***No pharmacotherapy at this time***
- The patient is at **35 weeks gestation** and in **active labor** (5 cm dilated, 60% effacement, regular contractions with adequate Montevideo units). At this gestational age, labor is typically allowed to progress without intervention unless there are complications.
- Pharmacotherapy to stop labor (tocolysis) or induce fetal lung maturity (corticosteroids) is generally not indicated at or beyond 34 weeks gestation in uncomplicated cases.
*Magnesium sulfate*
- This is primarily used for **fetal neuroprotection** in anticipated preterm birth before 32 weeks gestation, or as a **tocolytic** to inhibit contractions, neither of which is indicated here.
- The patient is 35 weeks, beyond the typical window for neuroprotection, and stopping labor is not appropriate given her advanced dilation and gestational age.
*Dexamethasone*
- **Corticosteroids** like dexamethasone are administered to accelerate **fetal lung maturity** in cases of anticipated preterm birth, typically between 24 and 34 weeks gestation.
- At 35 weeks, the benefits of corticosteroids for lung maturity are minimal and generally not recommended.
*Oxytocin*
- **Oxytocin** is used to **induce or augment labor** if contractions are inadequate or to prevent **postpartum hemorrhage**.
- This patient is already in active, effective labor with adequate contractions (220 MVU in 10 minutes), so oxytocin for augmentation is not needed.
*Terbutaline*
- **Terbutaline** is a **beta-agonist tocolytic** used to relax the uterus and stop preterm labor.
- Given the patient's gestational age of 35 weeks and the progression of her labor (5 cm dilated), stopping contractions is not the appropriate management.
Cervical ripening methods US Medical PG Question 7: A 31-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the emergency department for sudden leakage of clear vaginal fluid. Her pregnancy has been uncomplicated. Her first child was born at term by vaginal delivery. She has no history of serious illness. She does not drink alcohol or smoke cigarettes. Current medications include vitamin supplements. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Speculum examination demonstrates clear fluid in the cervical canal. The fetal heart rate is reactive at 160/min with no decelerations. Tocometry shows uterine contractions. Nitrazine testing is positive. She is started on indomethacin. Which of the following is the most appropriate next step in management?
- A. Administer betamethasone and ampicillin (Correct Answer)
- B. Administer betamethasone, ampicillin, and proceed with cesarean section
- C. Administer betamethasone, ampicillin, and proceed with induction of labor
- D. Administer ampicillin and perform amnioinfusion
- E. Administer ampicillin and test amniotic fluid for fetal lung maturity
Cervical ripening methods Explanation: ***Administer betamethasone and ampicillin***
- This patient presents with **preterm premature rupture of membranes (PPROM)** at 32 weeks' gestation, indicated by clear vaginal fluid and positive nitrazine test. Given the preterm status, **antenatal corticosteroids (betamethasone)** are crucial for fetal lung maturity, and **antibiotics (ampicillin)** are necessary to prevent intrauterine infection.
- She is not in active labor and the fetus is stable, so conservative management with these medications is appropriate, allowing for continued gestation while mitigating risks associated with prematurity and infection.
*Administer betamethasone, ampicillin, and proceed with cesarean section*
- While betamethasone and ampicillin are appropriate, **proceeding directly with a cesarean section** is not indicated as the patient is not in active labor and there are no signs of fetal distress or immediate need for delivery.
- Cesarean section carries maternal risks and is reserved for specific indications such as non-reassuring fetal status, malpresentation, or contraindications to vaginal delivery.
*Administer betamethasone, ampicillin, and proceed with induction of labor*
- Administering betamethasone and ampicillin is correct, but **inducing labor immediately** is not the most appropriate step at 32 weeks with PPROM in a stable patient without chorioamnionitis.
- The goal at this gestational age is typically to prolong the pregnancy to allow for further fetal development, unless there are complications that necessitate delivery, such as chorioamnionitis or non-reassuring fetal testing.
*Administer ampicillin and perform amnioinfusion*
- Ampicillin is appropriate for infection prophylaxis in PPROM, but **amnioinfusion** is generally reserved for cases of **oligohydramnios** with umbilical cord compression, particularly during labor.
- While oligohydramnios can result from PPROM, amnioinfusion is not a standard or primary intervention in the initial management of PPROM before labor onset.
*Administer ampicillin and test amniotic fluid for fetal lung maturity*
- Ampicillin is appropriate, but **testing amniotic fluid for fetal lung maturity** is less critical in this scenario, as corticosteroids will be administered regardless.
- Given the 32-week gestation, fetal lungs are unlikely to be fully mature, and waiting for test results would delay essential interventions (i.e., corticosteroids) that improve fetal outcomes.
Cervical ripening methods US Medical PG Question 8: A 22-year-old female presents to her PCP after having unprotected sex with her boyfriend 2 days ago. She has been monogamous with her boyfriend but is very concerned about pregnancy. The patient requests emergency contraception to decrease her likelihood of getting pregnant. A blood hCG test returns negative. The PCP prescribes the patient ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg to be taken 12 hours apart. What is the most likely mechanism of action for this combined prescription?
- A. Inhibition or delayed ovulation (Correct Answer)
- B. Interference of corpus luteum function
- C. Thickening of cervical mucus with sperm trapping
- D. Tubal constriction inhibiting sperm transportation
- E. Alteration of the endometrium impairing implantation of the fertilized egg
Cervical ripening methods Explanation: ***Inhibition or delayed ovulation***
- The high doses of **estrogen** and **progestin** in the combined emergency contraception pill primarily act by suppressing the **luteinizing hormone (LH) surge**, which is essential for ovulation.
- By inhibiting or delaying ovulation, the pill prevents the release of an egg, thus preventing fertilization since sperm cannot meet an egg.
*Interference of corpus luteum function*
- While hormonal contraceptives can affect the **corpus luteum**, high-dose emergency contraception primarily acts *before* the formation of a mature corpus luteum by preventing ovulation itself.
- Once the corpus luteum is formed, its function is usually maintained if pregnancy occurs, and emergency contraception given *after* implantation is generally ineffective at terminating a pregnancy.
*Thickening of cervical mucus with sperm trapping*
- This is a well-known mechanism of action for *continuous* hormonal contraception (e.g., daily birth control pills), where lower, consistent doses of progestin make cervical mucus impenetrable to sperm.
- While it might play a *minor* role, it is not the primary mechanism of action for high-dose emergency contraception administered acutely, which mainly targets ovulation.
*Tubal constriction inhibiting sperm transportation*
- There is no strong evidence to suggest that combined emergency contraception pills cause **tubal constriction** to significantly impair sperm or egg transport.
- The main sites of action are the **hypothalamic-pituitary-ovarian axis** (for ovulation) and possibly the endometrium (for implantation), not direct tubal motility.
*Alteration of the endometrium impairing implantation of the fertilized egg*
- While hormonal contraceptives can alter the **endometrium** making it less receptive to implantation, this is considered a *secondary* or less significant mechanism for combined emergency contraception.
- The primary goal and most effective action of these pills is to prevent fertilization by inhibiting ovulation, especially when taken shortly after unprotected intercourse and before implantation.
Cervical ripening methods US Medical PG Question 9: A 26-year-old G1P0 female who is 39 weeks pregnant presents to the emergency department in labor. She reports following her primary care physician’s recommendations throughout her pregnancy and has not had any complications. During delivery, the baby’s head turtled back into the vaginal canal and did not advance any further. The neonatal intensivist was called for shoulder dystocia and a baby girl was able to be delivered vaginally 6 minutes later. Upon initial assessment, the baby appeared pale throughout, had her arms and legs flexed without active motion, and had some flexion of extremities when stimulated. Her pulse is 120/min and had irregular respirations. What is this baby’s initial APGAR score?
- A. 5 (Correct Answer)
- B. 6
- C. 7
- D. 4
- E. 3
Cervical ripening methods Explanation: ***5***
- The APGAR score is calculated based on five criteria: **Appearance**, **Pulse**, **Grimace**, **Activity**, and **Respiration**.
- This baby's score is calculated as follows: **Appearance** (pale all over) = 0, **Pulse** (120/min) = 2, **Grimace** (some flexion of extremities with stimulation) = 1, **Activity** (arms and legs flexed without active motion) = 1, and **Respiration** (irregular) = 1.
- Total score: 0 + 2 + 1 + 1 + 1 = **5 points**
- A score of 5 indicates **moderate neonatal compromise** requiring close monitoring and possible intervention.
*4*
- A score of 4 would indicate more severe compromise, such as absent respirations (0 points) rather than irregular respirations (1 point).
- This baby has irregular respirations present, which earns 1 point, not 0 points.
*6*
- A score of 6 would require improvement in at least one category, such as **acrocyanosis** (blue extremities but pink body = 1 point for appearance) instead of pallor throughout.
- This baby's complete pallor limits the score to 5.
*7*
- A score of 7 or higher is generally considered reassuring and indicates a **healthy transition** from intrauterine to extrauterine life.
- This baby's concerning signs, including **complete pallor**, **irregular respirations**, and **poor muscle tone**, are inconsistent with a score of 7.
*3*
- A score of 3 would indicate severe depression with findings such as **heart rate less than 100 bpm**, completely absent reflexes, or flaccid muscle tone.
- This baby has a reassuring pulse of 120/min (2 points), some reflex response (1 point), and some muscle tone (1 point), making the total score higher than 3.
Cervical ripening methods US Medical PG Question 10: Five minutes after initiating a change of position and oxygen inhalation, the oxytocin infusion is discontinued. A repeat CTG that is done 10 minutes later shows recurrent variable decelerations and a total of 3 uterine contractions in 10 minutes. Which of the following is the most appropriate next step in management?
- A. Restart oxytocin infusion
- B. Emergent Cesarean section
- C. Administer terbutaline
- D. Monitor without intervention
- E. Amnioinfusion (Correct Answer)
Cervical ripening methods Explanation: ***Amnioinfusion***
- **Recurrent variable decelerations** persisting after discontinuing oxytocin and changing maternal position often indicate **cord compression**, which can be relieved by amnioinfusion.
- Adding fluid to the amniotic cavity **cushions the umbilical cord**, reducing compression during uterine contractions.
*Restart oxytocin infusion*
- Reinitiating oxytocin would likely **worsen the recurrent variable decelerations** by increasing uterine contraction frequency and intensity, thereby exacerbating cord compression.
- The goal is to alleviate fetal distress, not to intensify uterine activity that is already causing issues.
*Emergent Cesarean section*
- While an emergent Cesarean section is indicated for **unresolved fetal distress**, it's usually considered after less invasive measures, such as amnioinfusion, have failed.
- There is still an opportunity for a simpler intervention to resolve the issue before resorting to surgery.
*Administer terbutaline*
- Terbutaline is a **tocolytic agent** used to reduce uterine contractions, which can be helpful in cases of tachysystole or hyperstimulation.
- In this scenario, the contraction frequency is low (3 in 10 minutes), so reducing contractions is not the primary aim; rather, the focus is on resolving the cord compression causing decelerations.
*Monitor without intervention*
- **Recurrent variable decelerations** are an concerning sign of **fetal distress** and require intervention to prevent potential harm to the fetus.
- Simply monitoring without intervention would be inappropriate and could lead to worsening fetal hypoxemia and acidosis.
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