A 23-year-old woman presents to her gynecologist for painful menses. Her menses are regular, occurring every 28 days and lasting approximately 4 days. Menarche was at age 12. Over the past 6 months, she has started to develop aching pelvic pain during the first 2 days of her menstrual period. Ibuprofen provides moderate relief of her symptoms. She denies nausea, vomiting, dyschezia, dyspareunia, irregular menses, or menses that are heavier than usual. Her past medical history is notable for chlamydia 4 years ago that was treated appropriately. She currently takes no medications. She works as a copywriter and does not smoke or drink. She has been in a monogamous relationship with her boyfriend for the past 3 years. They use condoms intermittently. Her temperature is 98.6°F (37°C), blood pressure is 111/69 mmHg, pulse is 92/min, and respirations are 18/min. Pelvic examination demonstrates a normal appearing vagina with no adnexal or cervical motion tenderness. The uterus is flexible and anteverted. Which of the following is the underlying cause of this patient's pain?
Q2
A 26-year-old gravida 1 at 36 weeks gestation is brought to the emergency department by her husband complaining of contractions lasting up to 2 minutes. The contractions are mostly in the front of her abdomen and do not radiate. The frequency and intensity of contractions have not changed since the onset. The patient worries that she is in labor. The blood pressure is 125/80 mm Hg, the heart rate is 96/min, the respiratory rate is 15/min, and the temperature 36.8°C (98.2℉). The physical examination is unremarkable. The estimated fetal weight is 3200 g (6.6 lb). The fetal heart rate is 146/min. The cervix is not dilated. The vertex is at the -4 station. Which of the following would be proper short-term management of this woman?
Q3
A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?
Q4
A 63-year-old woman with a past medical history significant for hypertension presents to the outpatient clinic for evaluation of vaginal dryness, loss of libido, and hot flashes. These symptoms have been progressively worsening over the past 3 months. Her vital signs are: blood pressure 131/81 mm Hg, pulse 68/min, and respiratory rate 16/min. She is afebrile. On further review of systems, she endorses having irregular periods for almost a year, and asks if she has begun menopause. Which of the following parameters is required to formally diagnosis menopause in this patient?
Q5
One day after giving birth to a 4050-g (8-lb 15-oz) male newborn, a 22-year-old woman experiences involuntary loss of urine. The urine loss occurs intermittently in the absence of an urge to urinate. It is not exacerbated by sneezing or coughing. Pregnancy was uncomplicated except for two urinary tract infections that were treated with nitrofurantoin. Delivery was complicated by prolonged labor and severe labor pains; the patient received epidural analgesia. Her temperature is 36.2°C (97.2°F), pulse is 70/min, and blood pressure is 118/70 mm Hg. The abdomen is distended and tender to deep palpation. Pelvic examination shows a uterus that extends to the umbilicus; there is copious thick, whitish-red vaginal discharge. Neurologic examination shows no abnormalities. Which of the following is the most likely cause of this patient's urinary incontinence?
Q6
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?
Q7
A 15-year-old girl is brought to the physician by her parents because she has not had menstrual bleeding for the past 2 months. Menses had previously occurred at irregular 15–45 day intervals with moderate to heavy flow. Menarche was at the age of 14 years. Eight months ago, she was diagnosed with bipolar disorder and treatment with risperidone was begun. Her parents report that she is very conscious of her weight and appearance. She is 168 cm (5 ft 5 in) tall and weighs 76 kg (168 lb); BMI is 26.9 kg/m2. Pelvic examination shows a normal vagina and cervix. Serum hormone studies show:
Prolactin 14 ng/mL
Follicle-stimulating hormone 5 mIU/mL
Luteinizing hormone 5.2 mIU/mL
Progesterone 0.9 ng/mL (follicular N <3; luteal N >3–5)
Testosterone 2.7 nmol/L (N <3.5)
A urine pregnancy test is negative. Which of the following is the most likely cause of her symptoms?
Q8
You are the intern on the labor and delivery floor. Your resident asks you to check on the patient in Bed 1. She is a 27-year-old prima gravida with no significant past medical history. She has had an uncomplicated pregnancy and has received regular prenatal care. You go to her bedside and glance at the fetal heart rate tracing (Image A). What is the most likely cause of this finding?
Q9
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?
Q10
A 28-year-old primigravid woman at 36 weeks' gestation comes to the emergency department for 2 hours of contractions. Her pregnancy has been uncomplicated. The contractions occur once every 20–30 minutes, last less than 30 seconds, and have been consistent in intensity and duration since onset. During that time there has been an increase in fetal movements. Her temperature is 37.1°C (98.8°F), pulse is 98/min, and blood pressure is 104/76 mm Hg. Pelvic examination shows clear cervical mucus and a firm uterus consistent in size with a 36-week gestation. The cervix is 0% effaced and undilated; the vertex is at -3 station. The fetal heart rate is reassuring. After an hour of monitoring in the emergency department, the character of the contractions and pelvic examination findings remain unchanged. Which of the following is the most appropriate next step?
Stages of labor US Medical PG Practice Questions and MCQs
Question 1: A 23-year-old woman presents to her gynecologist for painful menses. Her menses are regular, occurring every 28 days and lasting approximately 4 days. Menarche was at age 12. Over the past 6 months, she has started to develop aching pelvic pain during the first 2 days of her menstrual period. Ibuprofen provides moderate relief of her symptoms. She denies nausea, vomiting, dyschezia, dyspareunia, irregular menses, or menses that are heavier than usual. Her past medical history is notable for chlamydia 4 years ago that was treated appropriately. She currently takes no medications. She works as a copywriter and does not smoke or drink. She has been in a monogamous relationship with her boyfriend for the past 3 years. They use condoms intermittently. Her temperature is 98.6°F (37°C), blood pressure is 111/69 mmHg, pulse is 92/min, and respirations are 18/min. Pelvic examination demonstrates a normal appearing vagina with no adnexal or cervical motion tenderness. The uterus is flexible and anteverted. Which of the following is the underlying cause of this patient's pain?
A. Intrauterine adhesions
B. Endometrial gland invasion into the uterine myometrium
C. Extra-uterine endometrial gland formation
D. Submucosal myometrial proliferation
E. Prostaglandin-induced myometrial contraction (Correct Answer)
Explanation: ***Prostaglandin-induced myometrial contraction***
- The patient's presentation of **primary dysmenorrhea** is characterized by painful menses despite a normal pelvic exam, with symptoms relieved by ibuprofen, indicating a role for **prostaglandins** in causing uterine contractions.
- **Absence of dyspareunia**, dyschezia, heavy bleeding, or abnormal uterine findings on examination rules out secondary causes of dysmenorrhea.
*Intrauterine adhesions*
- **Intrauterine adhesions**, or Asherman's syndrome, usually cause **hypomenorrhea** or **amenorrhea** due to scarring of the uterine cavity, not painful but otherwise regular menses.
- While chlamydia can lead to pelvic inflammatory disease and uterine scarring, her current symptoms are not consistent with significant intrauterine adhesions.
*Endometrial gland invasion into the uterine myometrium*
- This describes **adenomyosis**, which typically presents with **dysmenorrhea** and **heavy menstrual bleeding (menorrhagia)**, sometimes with a diffusely enlarged, tender, "boggy" uterus on examination.
- The patient in this case denies heavy menses and has a normal, flexible uterus on examination.
*Extra-uterine endometrial gland formation*
- This refers to **endometriosis**, which typically causes **dysmenorrhea**, **dyspareunia**, and **dyschezia** due to endometrial tissue implants outside the uterus.
- Her denial of dyspareunia and dyschezia, along with the normal pelvic exam, makes endometriosis less likely as the primary cause.
*Submucosal myometrial proliferation*
- This describes a **submucosal leiomyoma (fibroid)**, which commonly causes **heavy menstrual bleeding**, prolonged periods, and sometimes pelvic pressure or pain, depending on size and location.
- The patient's regular flow, normal duration, and lack of heavy bleeding or uterine enlargement make submucosal fibroids an unlikely cause of her pain.
Question 2: A 26-year-old gravida 1 at 36 weeks gestation is brought to the emergency department by her husband complaining of contractions lasting up to 2 minutes. The contractions are mostly in the front of her abdomen and do not radiate. The frequency and intensity of contractions have not changed since the onset. The patient worries that she is in labor. The blood pressure is 125/80 mm Hg, the heart rate is 96/min, the respiratory rate is 15/min, and the temperature 36.8°C (98.2℉). The physical examination is unremarkable. The estimated fetal weight is 3200 g (6.6 lb). The fetal heart rate is 146/min. The cervix is not dilated. The vertex is at the -4 station. Which of the following would be proper short-term management of this woman?
A. Reassurance, hydration, and ambulation (Correct Answer)
B. Admit to the Obstetrics Department for observation
C. Manage with terbutaline
D. Admit to the Obstetrics Department in preparation for labor induction
E. Perform an ultrasound examination
Explanation: ***Reassurance, hydration, and ambulation***
- This patient is experiencing **Braxton-Hicks contractions**, which are irregular, do not cause cervical change, and often resolve with hydration and rest or light activity.
- Given her stable vital signs, normal fetal heart rate, and undilated cervix, these interventions are appropriate to differentiate from true labor and provide comfort.
*Admit to the Obstetrics Department for observation*
- Admission for observation is unnecessary as there are no signs of **true labor** (cervical dilation or effacement) or fetal distress.
- The contractions are described as not changing in frequency or intensity and are localized to the anterior abdomen, consistent with **false labor**.
*Manage with terbutaline*
- **Terbutaline** is a tocolytic used to stop or prevent premature labor, but this patient is at 36 weeks gestation, which is near term, and not in true labor.
- Using a tocolytic for **Braxton-Hicks contractions** is not indicated and can have adverse effects.
*Admit to the Obstetrics Department in preparation for labor induction*
- There is no indication for **labor induction** as the patient is not in active labor and has not reached her due date.
- Labor induction is reserved for medical or obstetric indications, which are not present here.
*Perform an ultrasound examination*
- An ultrasound has already provided an estimated fetal weight and the fetal heart rate is normal, suggesting no immediate need for further **ultrasound evaluation**.
- There are no clinical signs to suggest fetal distress or other complications that would warrant an **urgent ultrasound**.
Question 3: A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?
A. Vibroacoustic stimulation
B. Routine monitoring (Correct Answer)
C. Administer tocolytics
D. Emergent cesarean delivery
E. Placement of fetal scalp electrode
Explanation: ***Routine monitoring***
- The presented FHR tracing exhibits a **normal baseline rate** (145/min), **moderate variability** (≥15/min), and the presence of **accelerations**, indicating a reassuring fetal status.
- The described decelerations are **variable decelerations** due to their sudden onset, nadir within 30 seconds, and variable relationship to contractions, which are generally benign unless prolonged, deep, or repetitive. Given the otherwise reassuring status, continued routine monitoring is appropriate.
*Vibroacoustic stimulation*
- This intervention is used to elicit **fetal accelerations** or movement during non-stress tests (NSTs) when the fetus is quiet or shows a non-reactive pattern.
- In this case, the fetus is already showing **accelerations** and moderate variability, so stimulation is not needed to assess fetal well-being.
*Administer tocolytics*
- **Tocolytics** are used to stop or slow down labor, typically in cases of preterm labor or uterine tachysystole causing fetal distress.
- This patient is at **38 weeks' gestation** and in active labor, and there are no signs of fetal distress warranting the cessation of contractions.
*Emergent cesarean delivery*
- **Emergent cesarean delivery** is indicated for acute fetal distress, such as prolonged decelerations, significant bradycardia, or absent variability in conjunction with other concerning FHR patterns.
- The FHR tracing described is largely reassuring with moderate variability and accelerations, and the variable decelerations are not indicative of immediate threat, making emergent delivery unnecessary.
*Placement of fetal scalp electrode*
- A **fetal scalp electrode** provides a more accurate and continuous measure of the FHR, often used when external monitoring is difficult or when there are concerns about the reliability of the tracing.
- While it can be useful in some situations, the current tracing is **interpretable as reassuring**, making invasive monitoring currently unnecessary.
Question 4: A 63-year-old woman with a past medical history significant for hypertension presents to the outpatient clinic for evaluation of vaginal dryness, loss of libido, and hot flashes. These symptoms have been progressively worsening over the past 3 months. Her vital signs are: blood pressure 131/81 mm Hg, pulse 68/min, and respiratory rate 16/min. She is afebrile. On further review of systems, she endorses having irregular periods for almost a year, and asks if she has begun menopause. Which of the following parameters is required to formally diagnosis menopause in this patient?
A. Increased serum follicle-stimulating hormone (FSH)
B. Increased serum luteinizing hormone (LH)
C. Cessation of menses for at least 12 months (Correct Answer)
D. Pelvic ultrasound demonstrating decreased follicular activity
E. Increased total cholesterol
Explanation: ***Cessation of menses for at least 12 months***
- The formal diagnosis of **menopause** is clinical, defined as 12 consecutive months of **amenorrhea** in the absence of other physiological or pathological causes.
- This criterion indicates the **cessation of ovarian function** without requiring lab tests, especially in women over 40.
*Increased serum follicle-stimulating hormone (FSH)*
- While an **elevated FSH level** is a biochemical indicator of declining ovarian function, it is not strictly required for a clinical diagnosis of menopause, particularly in older women with typical symptoms and amenorrhea.
- FSH levels can fluctuate during the **perimenopausal period**, making a single measurement less definitive than the clinical criterion of 12 months without menses.
*Increased serum luteinizing hormone (LH)*
- Similar to FSH, **LH levels** typically rise during menopause due to reduced estrogen feedback, but an elevated LH is not part of the formal clinical diagnostic criteria for menopause.
- The **FSH-to-LH ratio** can also be used, but the 12-month amenorrhea rule remains the primary diagnostic standard.
*Pelvic ultrasound demonstrating decreased follicular activity*
- A pelvic ultrasound can show **decreased ovarian volume** and a lack of developing follicles, indicating reduced ovarian activity, but this is not a required diagnostic parameter for menopause.
- Clinical history and the 12-month cessation of menses are sufficient for diagnosis, making **imaging studies** generally unnecessary unless there are other concerns.
*Increased total cholesterol*
- While **elevated cholesterol levels** can be associated with menopause due to changes in estrogen, it is a metabolic consequence or associated risk factor, not a diagnostic criterion for menopause itself.
- Menopause can lead to an increased risk of **cardiovascular disease**, which includes dyslipidemia, but this is a secondary effect, not a primary diagnostic marker.
Question 5: One day after giving birth to a 4050-g (8-lb 15-oz) male newborn, a 22-year-old woman experiences involuntary loss of urine. The urine loss occurs intermittently in the absence of an urge to urinate. It is not exacerbated by sneezing or coughing. Pregnancy was uncomplicated except for two urinary tract infections that were treated with nitrofurantoin. Delivery was complicated by prolonged labor and severe labor pains; the patient received epidural analgesia. Her temperature is 36.2°C (97.2°F), pulse is 70/min, and blood pressure is 118/70 mm Hg. The abdomen is distended and tender to deep palpation. Pelvic examination shows a uterus that extends to the umbilicus; there is copious thick, whitish-red vaginal discharge. Neurologic examination shows no abnormalities. Which of the following is the most likely cause of this patient's urinary incontinence?
A. Current urinary tract infection
B. Damage to nerve fibers
C. Recurrent urinary tract infections
D. Prolonged labor
E. Bladder atony (Correct Answer)
Explanation: **Bladder atony**
- The patient's symptoms of **involuntary, intermittent urine loss** without urgency, particularly after a prolonged and complicated delivery of a macrosomic infant, are highly suggestive of **bladder atony**.
- **Uterine distension** and **tenderness to deep palpation** further support the diagnosis, as an overdistended bladder can lead to this condition.
*Current urinary tract infection*
- While UTIs can cause urinary symptoms, the absence of fever, dysuria, or strong urinary urgency in this patient makes a **current UTI less likely** as the primary cause.
- The symptoms of **intermittent loss without urge** in the postpartum period are not typical for an active UTI.
*Damage to nerve fibers*
- Though prolonged labor can cause nerve damage, the patient's **neurologic examination is noted as normal**, making direct nerve fiber damage an unlikely cause of the incontinence.
- Nerve damage typically presents with more distinct neurological deficits or constant, rather than intermittent, leakage.
*Recurrent urinary tract infections*
- While she had two UTIs during pregnancy, this history alone does not explain the **acute onset of involuntary, non-urge incontinence** immediately postpartum.
- Past UTIs do not directly cause bladder atony or the specific type of overflow incontinence described.
*Prolonged labor*
- **Prolonged labor** is a **contributing factor** to bladder atony due to prolonged pressure on the bladder and potential nerve stretching, but it is not the direct cause of the incontinence itself.
- The direct cause is the resulting **atonic bladder**, which leads to overflow.
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
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.
Question 7: A 15-year-old girl is brought to the physician by her parents because she has not had menstrual bleeding for the past 2 months. Menses had previously occurred at irregular 15–45 day intervals with moderate to heavy flow. Menarche was at the age of 14 years. Eight months ago, she was diagnosed with bipolar disorder and treatment with risperidone was begun. Her parents report that she is very conscious of her weight and appearance. She is 168 cm (5 ft 5 in) tall and weighs 76 kg (168 lb); BMI is 26.9 kg/m2. Pelvic examination shows a normal vagina and cervix. Serum hormone studies show:
Prolactin 14 ng/mL
Follicle-stimulating hormone 5 mIU/mL
Luteinizing hormone 5.2 mIU/mL
Progesterone 0.9 ng/mL (follicular N <3; luteal N >3–5)
Testosterone 2.7 nmol/L (N <3.5)
A urine pregnancy test is negative. Which of the following is the most likely cause of her symptoms?
A. Primary ovarian insufficiency
B. Uterine leiomyomas
C. Anovulatory cycles (Correct Answer)
D. Adverse effect of medication
E. Self-induced vomiting
Explanation: ***Anovulatory cycles***
- The patient's irregular menses, moderate to heavy flow, and low progesterone level (indicating a lack of ovulation) point toward **anovulatory cycles**. Her **BMI of 26.9 kg/m2** indicates overweight/obesity, a common risk factor for anovulation due to insulin resistance and hormonal imbalances.
- Given her age, newly diagnosed bipolar disorder treated with **risperidone** (which can induce hyperprolactinemia, though her prolactin here is normal), and prior irregular but self-sustaining menses, anovulation is the most encompassing explanation for her current secondary amenorrhea.
*Primary ovarian insufficiency*
- This condition involves ovarian failure before age 40, characterized by **elevated FSH and LH levels** (gonadotropin levels would be high due to lack of ovarian feedback), which are not present in this patient (FSH 5 mIU/mL, LH 5.2 mIU/mL).
- While it can manifest as irregular menses and amenorrhea, the normal gonadotropin levels make this diagnosis unlikely.
*Uterine leiomyomas*
- **Uterine leiomyomas** (fibroids) can cause heavy or irregular bleeding but are very uncommon in a 15-year-old and typically would not cause amenorrhea without other severe symptoms.
- Furthermore, leiomyomas would not explain the **low progesterone** level indicative of anovulation.
*Adverse effect of medication*
- While **risperidone** can cause **hyperprolactinemia** leading to amenorrhea, this patient's prolactin level (14 ng/mL) is within the normal range.
- Therefore, the medication is unlikely to be directly causing her amenorrhea through this common mechanism.
*Self-induced vomiting*
- **Self-induced vomiting**, suggestive of an eating disorder like bulimia nervosa, could contribute to menstrual irregularities due to nutritional deficiencies and metabolic disturbances.
- However, this patient's **BMI of 26.9 kg/m2** is above the normal range, making an eating disorder with severe weight loss less likely, although other eating disorders (like atypical anorexia or bulimia without significant weight loss) could exist.
Question 8: You are the intern on the labor and delivery floor. Your resident asks you to check on the patient in Bed 1. She is a 27-year-old prima gravida with no significant past medical history. She has had an uncomplicated pregnancy and has received regular prenatal care. You go to her bedside and glance at the fetal heart rate tracing (Image A). What is the most likely cause of this finding?
A. Fetal head compression (Correct Answer)
B. Congenital heart block
C. Fetal distress
D. Cord compression
E. Utero-placental insufficiency
Explanation: ***Fetal head compression***
- The image shows **early decelerations**, which are characterized by a gradual decrease and return of the fetal heart rate, mirroring the **contraction pattern**.
- Early decelerations are considered benign and are typically caused by **vaginal stimulation** or **fetal head compression** during contractions, increasing vagal tone.
*Congenital heart block*
- Congenital heart block would manifest as a **persistent bradycardia** (low baseline heart rate) or significant rhythm abnormalities, not decelerations synchronized with contractions.
- This condition is often associated with maternal **autoimmune diseases** such as lupus, which is not indicated in this patient's history.
*Fetal distress*
- Fetal distress is typically indicated by **late decelerations** (decelerations that occur after the peak of the contraction) or **prolonged decelerations**, often accompanied by reduced variability.
- While other forms of decelerations can signify distress, early decelerations are generally considered reassuring.
*Cord compression*
- Cord compression typically causes **variable decelerations**, which are abrupt, unpredictable drops in fetal heart rate varying in duration, intensity, and timing relative to contractions.
- These decelerations often have a 'U' or 'V' shape, which is different from the mirrored pattern seen in early decelerations.
*Utero-placental insufficiency*
- This condition is the cause of **late decelerations**, which are characterized by a gradual decrease in fetal heart rate that begins after the peak of the contraction and returns to baseline after the contraction ends.
- Late decelerations reflect **fetal hypoxemia** due to insufficient placental blood flow, a more concerning finding than early decelerations.
Question 9: 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)
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.
Question 10: A 28-year-old primigravid woman at 36 weeks' gestation comes to the emergency department for 2 hours of contractions. Her pregnancy has been uncomplicated. The contractions occur once every 20–30 minutes, last less than 30 seconds, and have been consistent in intensity and duration since onset. During that time there has been an increase in fetal movements. Her temperature is 37.1°C (98.8°F), pulse is 98/min, and blood pressure is 104/76 mm Hg. Pelvic examination shows clear cervical mucus and a firm uterus consistent in size with a 36-week gestation. The cervix is 0% effaced and undilated; the vertex is at -3 station. The fetal heart rate is reassuring. After an hour of monitoring in the emergency department, the character of the contractions and pelvic examination findings remain unchanged. Which of the following is the most appropriate next step?
A. Admit for continuous monitoring
B. Reassurance and discharge (Correct Answer)
C. Administer tocolytics
D. Perform cesarean delivery
E. Offer local or regional anesthesia
Explanation: ***Reassurance and discharge***
- The patient's symptoms (contractions every 20-30 minutes, lasting less than 30 seconds, consistent in intensity and duration, **no cervical changes**) are consistent with **Braxton Hicks contractions** rather than true labor.
- Given the reassuring fetal movements, normal vital signs, and unchanged cervical examination after an hour of monitoring, **reassurance and discharge** with instructions to return for signs of true labor are appropriate.
*Admit for continuous monitoring*
- Admission for continuous monitoring is indicated for **true labor**, suspected fetal distress, or complications requiring close observation.
- This patient's findings, including lack of cervical change and stable contraction pattern, do not meet criteria for admission.
*Administer tocolytics*
- **Tocolytics** are used to stop or slow down premature labor.
- This patient is at **36 weeks' gestation** (near term) and is not in true labor, making tocolytic administration inappropriate and unnecessary.
*Perform cesarean delivery*
- **Cesarean delivery** is indicated for obstetric emergencies, fetal distress, or failed vaginal delivery.
- There are no indications for an operative delivery at this time; the patient is not in active labor and both mother and fetus are stable.
*Offer local or regional anesthesia*
- **Local or regional anesthesia** (e.g., epidural) is typically offered for pain management during active labor.
- Since the patient is not in active labor, pain management for labor is not necessary.
