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OB/GYN APGO Test Bank Questions &
Answers. (All Correct)
An 18-year-old G1P0 woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable. She has not been taking prenatal vitamins. Her pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a white blood count 9,700/mL, hemoglobin 10.6 g/dL, mean corpuscular volume 88.2 fL (80.8 - 96.4) and platelets 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient's anemia? A. Folate deficiency B. Relative hemodilution of pregnancy C. Iron deficiency D. Beta thalassemia trait E. Alpha thalassemia trait - CORRECT ANSWER>>B. There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV. Folate deficiency results in a macrocytic anemia. Iron deficiency and thalassemias are associated with microcytic anemia.
A 34-year-old G3P1 woman at 26 weeks gestation reports "difficulty catching her breath," especially after exertion for the last two months. She is a non-smoker. She does not have any
history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64, pulse 88, respiratory rate 15, and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman's symptoms? A. Pulmonary embolism B. Mitral valve stenosis C. Physiologic dyspnea of pregnancy D. Peripartum cardiomyopathy E. Anemia - CORRECT ANSWER>>CORRECT ANSWER is C. Physical examination findings are not consistent with pulmonary embolus (e.g tachycardia, tachypnea, hypoxia, chest pain, signs of a DVT) or mitral stenosis (diastolic murmur, signs of heart failure). Physiologic dyspnea of pregnancy is present in up to 75% of women by the third trimester. Peripartum cardiomyopathy is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic function towards the end of pregnancy or in the several months following delivery. Symptoms include fatigue, shortness of breath, palpitations, and edema. The history and physical do not suggest a pathologic process, nor does her hemoglobin level.
A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and whitish sputum for the last three days. She reports that everyone in the family has been sick. She reports a high fever last night up to 102°F (38.9°C). She denies chest pain. She smokes a half-pack of cigarettes per day. She has a history of asthma with
Expiratory reserve capacity (ERC) decreased Residual volume (RV) decreased
What is the next best step in the evaluation of this patient?
A. Routine antenatal care B. Chest x-ray C. Arterial blood gas D. Spiral CT of the lungs E. Echocardiogram - CORRECT ANSWER>>A. The results of her PFT are consistent with normal physiologic changes in pregnancy. Inspiratory capacity increases by 15% during the third trimester because of increases in tidal volume and inspiratory reserve volume. The respiratory rate does not change during pregnancy, but the TV is increased which increases the minute ventilation, which is responsible for the respiratory alkalosis in pregnancy. Functional residual capacity is reduced to 80% of the non- pregnant volume by term. These combined lead to subjective shortness of breath during pregnancy.
A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty breathing, cough and frothy sputum. She was admitted for preterm labor 24 hours ago. She is a non-smoker. She has received 6 liters of Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: 100.2°F (37.9°C); respiratory rate 24; heart rate 110; blood pressure 132/85; pulse oximetry is 97% on a non-rebreather mask. She appears in distress. Lungs reveal bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show white blood cell count 17,500/mL with 94% segmented neutrophils. Potassium and
sodium are normal. Which of the following has most likely contributed to this patient's respiratory symptoms? A. Increased plasma osmolality B. Use of tocolytics C. Chorioamnionitis D. Preterm labor E. Increased systemic vascular resistance - CORRECT ANSWER>>B. This patient has pulmonary edema. Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia. Use of multiple tocolytics increases the susceptibility of pulmonary edema, especially with the use of isotonic fluids. Systemic vascular resistance is decreased during pregnancy. Women with chorioamnionitis are also more likely to develop pulmonary edema, but this is not usually the main cause unless the patient is in septic shock and this patient does not have chorioamnionitis.
A 25-year-old G1P0 woman is seen for an initial obstetrical appointment at eight weeks gestation. She has had a small ventricular septal defect (VSD) since birth. She has no surgical history and no limitations on her activity. Vital signs are: respiratory rate 12; heart rate 88; blood pressure 112/68. On physical examination: her skin appears normal; lungs are clear to auscultation; heart is a regular rate and rhythm. There is a grade IV/VI coarse pansystolic murmur at the left sternal border, with a thrill. Chest x-ray and ECG are normal. Which of the following is the correct statement regarding cardiovascular adaptation in this patient?
the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter.
A 34-year-old G4P2 woman at 18 weeks gestation presents with fatigue and occasional headache. She has a sister with Grave's disease. On physical exam, vital signs are normal. BMI is 27. Thyroid is difficult to palpate due to her body habitus. The remainder of her exam is unremarkable. Thyroid function studies show:
Results Reference Range TSH 1.8 mU/L 0.30 -5.5 mU/L Free T4 1.22 ng/dL 0.76 - 1.70 ng/dL Total T4 14.2 ng /dL 4.9 - 12.0 ng /dL Free T3 3.4 ng/dL 2.8 - 4.2 ng/dL Total T3 200 ng/dL 80 - 175 ng/dL
What is the next best step in the management of this patient?
A. Continue routine prenatal care B. Check anti-thyroid antibody levels C. Obtain a thyroid ultrasound D. Initiate propylthiouracil E. Initiate methimazole - CORRECT ANSWER>>A. Thyroid binding globulin (TBG) is increased due to increased circulating estrogens
with a concomitant increase in the total thyroxine. Free thyroxine (T4) remains relatively constant. Total triiodothyroxine (T3) levels also increase in pregnancy while free T3 levels do not change. In a pregnant patient without iodine deficiency, the thyroid gland may increase in size up to 10%. This patient's thyroid function is normal for pregnancy, and her symptoms of fatigue can be explained by other physiologic changes in pregnancy, including anemia, difficulty with sleep, and increase metabolic demand.
An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, scant vaginal bleeding and a "racing heart." These symptoms have been present on and off for the past four weeks. The patient has no significant past medical, surgical or family history. Vital signs are: temperature 98.6°F (37°C); heart rate 120; blood pressure 128/78. On physical examination: uterine fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal Doppler device; cervix is 1 cm dilated with pinkish/purple "fleshy" tissue protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T 3.2 (normal 0.7 - 2.5). An ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient? A. Repeat quantitative Beta-hCG B. Repeat t - CORRECT ANSWER>>D. This patient's presentation is classic for a molar pregnancy. Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease. Though a repeat quantitative Beta-hCG will be required
weeks ago. Review of her history is unremarkable and her entire family is in good health. Physical examination reveals a ten-week size uterus. Which of the following is the most appropriate next step in establishing this pregnancy's gestational age? A. Checking fetal heart tones B. Hysterosonogram C. Quantitative Beta-hCG D. Obstetrical ultrasound E. Quadruple screen - CORRECT ANSWER>>D. The patient's gestational age based on her LMP and the findings on physical exam are discordant. In this case, the most reliable method of confirming gestational age is a dating ultrasound. A quantitative Beta-hCG will not reliably predict the gestational age. The uterine size on physical exam is not the most accurate way to date a pregnancy. An ultrasound performed between 14 and 20 weeks gestation should be used to date the pregnancy if there is greater than a 10 day discrepancy from the menstrual dates. First trimester ultrasound provides the most accurate assessment of gestational age and can give an accurate estimated date of confinement (EDC) to within 3-5 days.
A 34-year-old G2P1 woman presents at 13 weeks gestation. She did not seek preconception counseling and is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family or social history. Which of the following tests is most effective in screening for Down syndrome in the second trimester? A. Quadruple screen B. Triple screen C. Amniotic fluid for alpha fetoprotein level D. Maternal serum alpha fetoprotein level
E. Nuchal translucency measurement with serum PAPP-A (pregnancy associated plasma protein-A) and free Beta-hCG level - CORRECT ANSWER>>A. The quadruple test (maternal serum alpha fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A) is the most effective screening test for Down syndrome in the second trimester. Down syndrome occurs in about 1 in 800 births in the absence of prenatal intervention. The efficacy of screening for Down syndrome is improved when additional components are added to the maternal serum alpha fetoprotein screening. The addition of unconjugated estriol and human chronic gonadotropin (the Triple Screen) results in a 69% detection rate for Down syndrome. Adding inhibin A to produce a quadruple screen achieves a detection rate of 80-85%. An amniotic fluid alpha fetoprotein level is unnecessary. Nuchal translucency measurement with maternal serum PAPP-A and free Beta-hCG (known as the combined test) is a first trimester screen for Down syndrome. It detects approximately 85% of cases of Down syndrome at a 5% false positive rate.
A 26-year-old G2P1 woman at 26 weeks gestation presents for a routine 50-gram glucose challenge test. After receiving a one-hour blood glucose value of 148 mg/dl, the patient has a follow up 100- gram three-hour oral glucose tolerance test with the following plasma values:
Fasting 102 mg/dl (normal ≤95 mg/dl) 1-hour 181 mg/dl (normal ≤180 mg/dl) 2-hour 162 mg/dl (normal ≤155 mg/dl) 3-hour 139 mg/dl (normal ≤140 mg/dl) - CORRECT ANSWER>>B. This patient has three values on the three-hour glucose tolerance test that were abnormal. Initial management should include
disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes.
A 32-year-old G3P2 woman has delivered a previous child with anencephaly. What is the appropriate recommended dose of folic acid for this woman?
A. 0.4 mg B. 0.8 mg C. 1.0 mg D. 4 mg E. 8 mg - CORRECT ANSWER>>D. In 1991, the Centers for Disease Control and Prevention recommended that all women with a previous pregnancy complicated by a fetal neural tube defect ingest 4 mg of folic acid daily before conception and through the first trimester. In one analysis, this dose of folic acid in women at high risk reduced the incidence of neural tube defects by 85%. The recommended dose for non-high risk patients is 0.4mg/day.
A 35-year-old G1 woman with an IVF conceived 12 weeks gestation has a slightly elevated fetal nuchal translucency (2. multiples of the median), but her integrated first trimester screen shows no increased risk for Down syndrome or Trisomy 18. Still concerned about the increased nuchal translucency, the patient requests non-invasive testing to exclude other abnormalities. Which of the following is the next best step in the management of this patient?
A. Reassurance B. Monthly ultrasound to assess for fetal growth
C. Detailed ultrasound and fetal echocardiogram at approximately 18 - 20 weeks gestation D. Repeat first trimester screening E. Amniocentesis - CORRECT ANSWER>>C. The first trimester screen alone yields an 85% detection rate. The NT is the measurement of the fluid collection at the back of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and structural abnormalities as well as a number of genetic syndromes. Patients who desire non-invasive assessment of their risk for aneuploidy can have first trimester screen (a fetal nuchal translucency (NT) measurement and a maternal serum PAPP-A) and a second trimester quadruple screen. The sequential screen yields a 95% detection rate for Down syndrome at a 5% false-positive rate. Since the fetus in this case had a thickened NT, this patient should be scheduled to have a detailed fetal ultrasound and echocardiogram at 18-20 weeks to rule out anomalies. Amniocentesis would detect other chromosomal abnormalities, but is an invasive test. Of note, the American Congress of Obstetrics and Gynecology (ACOG) recommends that all patients be offered aneuploidy screening and invasive prenatal diagnosis as indicated.
A 23-year-old G1P0 woman at 38 weeks gestation, with an uncomplicated pregnancy, presents to labor and delivery with the complaint of lower abdominal pain and mild nausea for one day. Fetal kick counts are appropriate. Her review of symptoms is otherwise negative. Vital signs are: temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 14; fetal heart rate 140s, reactive, with no decelerations; tocometer shows irregular contractions every 2-8 minutes; fundal height 36 cm; cervix is firm, long, closed and posterior. A urine dipstick is
A. Discharge home with labor warnings B. 24 hour observation C. Biophysical profile D. Contraction stress test E. Induction of labor - CORRECT ANSWER>>A. The patient has reassuring fetal testing and may be discharged home with labor warnings: contractions every five minutes for one hour, rupture of membranes, fetal movement less than 10 per two hours or vaginal bleeding. A reactive non-stress test and normal AFI (modified biophysical profile) are sufficient to assess fetal well being at this time. Additional testing and interventions are not indicated at this time.
A 38-year-old G1P0 woman presents to the hospital at 39 weeks in early labor. She has had routine prenatal care and no antepartum complications to date. She reports good fetal movement and denies vaginal bleeding and leakage of fluid. What is the next best step in the initial assessment of this patient? A. Physical examination B. Nitrazine test C. Fetal ultrasound D. Biophysical profile E. Contraction stress test - CORRECT ANSWER>>A. The initial evaluation of patients presenting to the hospital for labor includes a review of the prenatal records with special focus on the antenatal complications and dating criteria, a focused history and a targeted physical examination to include maternal vital signs and fetal heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient's history suggests this, or if a patient is uncertain as to whether she has experienced leakage
of amniotic fluid. Performing a fetal ultrasound is not a routine part of an assessment in a patient who may be in early labor. A prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal weight, placental location or amniotic fluid volume.
A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and delivery reporting a gush of blood-tinged fluid approximately five hours ago and the onset of uterine contractions shortly thereafter. She reports contractions have become stronger and closer together over the past hour. The fetal heart rate is 140 to 150 with accelerations and no decelerations. Uterine contractions are recorded every 2-3 minutes. A pelvic exam reveals that the cervix is 4 cm dilated and 100 percent effaced. Fetal station is 0. After walking around for 30 minutes the patient is put back in bed after complaining of further discomfort. She requests an epidural. However, obtaining the fetal heart rate externally has become difficult because the patient cannot lie still. What is the most appropriate next step in the management of this patient?
A. Place the epidural B. Apply a fetal scalp electrode C. Perform a fetal ultrasound to asses - CORRECT ANSWER>>B. If the fetal heart rate cannot be confirmed using external methods, then the most reliable way to document fetal well-being is to apply a fetal scalp electrode. Putting in an epidural without confirming fetal status might be dangerous. Although ultrasound will provide information regarding the fetal heart rate, it is not practical to use this to monitor the fetus continuously while the epidural is placed. An intrauterine pressure catheter will provide
delivery of the fetus. Amnioinfusion is not indicated given the imminent delivery.
A 25-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with spontaneous onset of labor and spontaneous rupture of membranes. Cervical examination was 5 cm at presentation and 5 cm at last check, two hours ago. Presently, the patient is uncomfortable and notes strong contractions. You decide to place an intrauterine pressure catheter (IUPC). On placement, approximately 300 cc of frank blood and amniotic fluid flow out of the vagina. What is the most appropriate next step in the management of this patient? A. Emergent Cesarean delivery B. Withdraw the IUPC, monitor fetus and then replace if tracing reassuring C. Begin amnioinfusion D. Begin Pitocin augmentation E. Keep IUPC in position and connect to tocometer - CORRECT ANSWER>>B. If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. In this case, withdrawing the catheter, monitoring the fetus and observing for any signs of fetal compromise would be the most appropriate management. If the fetal status is found to be reassuring, then another attempt at placing the catheter may be undertaken.
A 19-year-old G1P0 woman at 39 weeks gestation presents in labor. She denies ruptured membranes. Her prenatal course was uncomplicated and ultrasound at 18 weeks revealed no fetal abnormalities. Her vital signs are: blood pressure 120/70; pulse
72; temperature 101.0° F (38.3° C); fundal height 36 cm; and estimated fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced and at +1 station. She receives 10 mg of morphine intramuscularly for pain and soon after has spontaneous rupture of the membranes. Light meconium-stained fluid was noted and, five minutes later, the fetal heart rate tracing revealed variable decelerations with good variability. What is the most likely cause for the variable decelerations? A. Umbilical cord compression B. Meconium C. Maternal fever D. Uteroplacental insufficiency E. Umbilical cord prolapse - CORRECT ANSWER>>A. Variable decelerations are typically caused by cord compression and are the most common decelerations seen in labor. Placental insufficiency is usually associated with late decelerations. Head compression typically causes early decelerations. Oligohydramnios can increase a patient's risk of having umbilical cord compression; however, it does not directly cause variable decelerations. Umbilical cord prolapse occurs in 0.2 to 0.6% of births. Sustained fetal bradycardia is usually observed.
A 34-year-old G1P0 woman at 39 weeks gestation presents in active labor. Her cervical examination an hour ago was 5 cm dilated, 90 percent effaced and 0 station. The baseline is 140 beats/minute. There is a deceleration after the onset of each of the last four contractions. She just had spontaneous rupture of membranes and is found to be completely dilated with the fetal head is at +3 station. What is the most likely etiology for these decelerations?
