USULAN UNHAS JULI 2019

UNHAS PUNYA

1. A 34-year-old Asian woman G4P3003 at 34 weeks’ gestation presents to L&D triage complaining of
hematuria, dysuria, and occasional contractions for 1 week. She also notes some occasional
vaginal spotting over the last 3 days. She denies any leakage of fluid or discharge. She denies
back or flank pain but has had some suprapubic discomfort. She had an anatomy ultrasound at 18
weeks, where she was noted to have normal fetal anatomy, normal AFI, and an anterior complete
placenta previa. She has no significant PMH. She has surgical history of three previous cesarean
sections at term. Her first cesarean section was 8 years ago in China for breech at term. Owing to
her social situation, she has not been able to schedule a repeat ultrasound at 30 weeks, as was
recommended at the time of her anatomy ultrasound. She has not had recent intercourse. Which of
the following is not an appropriate initial test to determine the etiology of this patient’s hematuria?
A. Urine analysis
B. Urine culture
C. SSE
D. CT scan of abdomen and pelvis
E. Abdominal ultrasound of uterus

2. You are assisting in a gynecologic oncology clinic when you see a 57-year-old G3 P3 female
patient who is a former nurse. She presents with 6 months of pelvic discomfort, increasing
abdominal girth, and early satiety. Physical exam reveals a large abdomino pelvic mass. A pelvic
ultrasound and CT scan show a 10-cm right ovarian mass, ascites, and studding of the peritoneum.
In your discussion with the patient you predict that this most likely represents a malignant ovarian
neoplasm. She asks about the primary method of treatment for ovarian carcinoma. You explain that
the mainstay of treatment for epithelial ovarian cancer is:
A. radiation therapy alone.
B. surgery alone.
C. surgery followed by chemotherapy.
D. surgery followed by radiation therapy.
E. chemoradiation alone.

3. A 33-year-old G2P1 woman presents to your office with a complaint of nipple discharge. She states
that it is milky in color, comes from both breasts, and is present even when she does not express it.
You perform a breast examination, and express milky-discharge from both breasts. You diagnose
her with galactorrhea. Which condition is not associated with galactorrhea?
A. Pregnancy
B. Breast abscess
C. Pituitary adenoma
D. Psychotropic medications
E. Hypothyroidism

4. A 28-year-old G2P1 woman with a history of a prior cesarean delivery presents at 36 weeks'
gestation with a complaint of vaginal bleeding. She notes no contractions, but awoke this morning
with vaginal bleeding equivalent to heavy menstrual flow. You obtain an ultrasound as part of her
workup for third trimester bleeding. Ultrasound is the primary diagnostic tool for which cause of third
trimester bleeding?
A. Uterine rupture
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B. Placental abruption
C. Placenta previa
D. Cervical neoplasm
E. Vaginal laceration

5. A 19-year-old G3 P1 at 31 weeks' gestation presents with contractions every 3 to 4 minutes. On

examination, her cervix is found to be dilated 2 cm and 50% effaced. The patient's history is
remarkable for a delivery at 33 weeks' gestation in her last pregnancy of a 5 lb 3 oz infant 3 years
ago, and a miscarriage 2 years ago. She has a history of a half pack per day smoking for 6 years.
Which of the following is the most predictive risk factor for recurrent preterm labor?
A. History of spontaneous abortion
B. Prior preterm delivery
C. Large fetus
D. Cigarette smoking
E. Teenage pregnancy

6. A 23-year-old G0 who has never had a Pap test or pelvic examination comes to the office to start
on birth control pills. She tells you her periods are regular but heavy and last 7 days, and she has
terrible cramps. She has been sexually active for the past 2 years with three different partners. She
uses condoms most of the time. You perform an examination, including STI testing and a Pap test
and prescribe a trial of oral contraceptive pills. Her STI testing is negative but her Pap test result is
“atypical squamous cells of undetermined significance (ASCUS)” and a reflex HPV test is negative.
What is your recommendation for this Pap test result?
A. Proceed to colposcopy
B. Repeat the Pap test in 3 months
C. Repeat the Pap test and HPV test in 3 years
D. Repeat the HPV test in 1 year
E. LEEP conization of the cervix

7. A 19-year-old G3 P1 patient with a history of a miscarriage in her last pregnancy presents to the
emergency department with some vaginal spotting. She reports that her last menstrual period
occurred 6 weeks earlier. She has had no vaginal discharge other than the spotting, no cramping,
and no abdominal pain. Her physical examination reveals a slightly enlarged uterus, no tenderness,
and a closed cervical os. A serum β-hCG level is sent off and returns 346. A pelvic ultrasound
shows no intrauterine pregnancy, a 2-cm left ovarian cyst, and no free fluid. Your diagnosis of this
patient is which of the following?
A. Threatened abortion/rule out ectopic pregnancy
B. Ectopic pregnancy
C. Inevitable abortion
D. Missed abortion
E. Normal pregnancy

8. A 19-year-old G1 P0 at 38 weeks' gestation presents to labor and delivery. On arrival, she is having
contractions every 2 to 3 minutes and claims that her water broke 2 days earlier but that she didn't
come in because she hadn'treached her due date. She has a temperature of 101.2°F, heart rate of
110, blood pressure of 116/72 mm Hg, and uterine tenderness on palpation. The fetal heart rate is
in the 170s with small accelerations and no decelerations. Which of the following is your diagnosis
of this patient?
A. Labor
B. Preterm labor
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C. Chorioamnionitis
D. Maternal fever
E. Preterm rupture of membranes

9. A 29-year-old G3 P2 at 38 weeks' gestation presents to labor and delivery complaining of the

sudden onset of abdominal pain and bright-red vaginal bleeding. On examination, her uterus is firm
and tender to palpation and the tocodynamometer reveals regular contractions every 1 to 2
minutes. The fetal heart monitor shows no evidence of fetal distress. The patient had a normal
ultrasound at week 34 that showed the infant in the vertex presentation. Which of the following is
the most likely diagnosis in this patient?
A. Labor
B. Premature rupture of membranes
C. Placenta accreta
D. Placenta previa
E. Placental abruption

10. A 35-year-old woman has been your patient for the past 5 years. You recently placed her on a
progestin-only birth control pill given her history of smoking one PPD for nearly 20 years. All of the
following are mechanisms of action for progestin-only contraceptive methods except:
A. Suppression of ovulation
B. Thickening of the cervical mucous
C. Making the endometrium unsuitable for implantation
D. Inhibiting sperm motility
E. Stimulating regression of the corpus luteum

11. A 23-year-old G1 P0 at 35 weeks' gestation presents with a vaginal gush of fluid. On sterile
speculum examination, the patient has a pool of clear fluid in the vagina that is nitrazine and fern
positive. She is contracting every 3 to 4minutes, and her cervix on visualization appears to be
dilated 2 to 3 cm. Which of the following is the best course of action?
A. Tocolysis with magnesium or terbutaline
B. Betamethasone and tocolysis
C. Betamethasone and no tocolysis
D. Expectant management
E. Amnio/dye test

12. A healthy 28-year-old G0 comes in to see you for increasingly painful periods. She and her
husband have been trying to conceive for the past year. The patient reports regular menses each
month, which are normal in length and amount of blood. However, a couple days before her
menses are due to begin she gets severe abdominal pain and cramping. The pain usually subsides
within a day or two of her menses beginning. More recently, her pain is lasting through her entire
period and she misses at least a day or two of work each month. She is also beginning to have pain
with intercourse as well. She takes ibuprofen with minimal pain relief for at least 7 days each
month. Her only other medication is the Ortho-Evra birth control patch, which she stopped using 1
year ago. On exam, her uterus is retroverted and not easily mobile. There is nodularity noted on the
uterosacral ligaments. A pelvic ultrasound reveals a normal uterus and normal bilateral adnexa.
What is the most appropriate initial management for this patient?
A. Diagnostic laparoscopy
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B. Oral contraceptive pills and NSAIDs

C. Depot Lupron with estrogen add-back
D. Danazol
E. Expectant management

13. As part of routine prenatal care, there are a series of tests offered throughout pregnancy. Usually,
these tests are delineated by the trimester in which they are offered. Which of the following tests
are routinely offered in the second trimester?
A. GBS
B. Hematocrit
C. Amniocentesis
D. Transvaginal ultrasound for dating
E. Fern test

14. A 27-year-old G0 presents to your clinic with irregular menses. She reports 4 to 5 menstrual cycles
per year for the past year. She also complains of worsening acne, and having to pluck dark hairs
from her upper lip, chin, and abdomen. Your physical examination is remarkable only for the hair
and acne she described, as well as obesity. You perform a bedside ultrasound that reveals multiple
small follicular cysts on her bilateral ovaries. You correctly diagnose her with polycystic ovary
syndrome. In PCOS, patients are likely to have which of the following physiologic changes:
A. Increased levels of FSH
B. Increased frequency of GnRH pulses
C. Low estradiol concentrations
D. Low free testosterone
E. Low inhibin levels

15. A 26-year-old G0 woman presents to your office with complaints of a palpable breast mass
discovered by her husband. She has no family history of breast cancer. You perform a clinical
breast examination and can palpate the mass as well. The next step in management of this patient
would be:
A. Diagnostic mammogram
B. Diagnostic ultrasound
C. Breast MRI
D. Core-needle biopsy
E. Excisional biopsy

16. A 23-year-old woman presents with multiple lesions on her labia and perineum. These tender
ulcers have been causing discomfort for 36 hours. The patient also complains of dysuria and
fatigue. On physical exam, she also has bilateral inguinal adenopathy. A Tzanck prep of one of the
lesions reveals multinucleated giant cells. The woman is concerned that this was transmitted
sexually and would like to be tested for other sexually transmitted diseases. Which of the following
tests should be ordered?
A. Rapid plasma reagin (RPR)
B. HIV
C. Chlamydiazyme DNA probe
D. Gonorrhea culture or DNA probe
E. All of the above

17. You are consulted on an 89-year-old inpatient in a nursing facility. Your patient has complete
eversion of the vagina. What is another term for this?
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A. Procidentia
B. Cystocele
C. Rectocele
D. Urethrocele
E. Enterocele
18. Micturition is voluntary and occurs with relaxation of the urethra and sustained contraction of the
bladder until emptying is complete. Sustained contraction of the detrusor muscle of the bladder
requires parasympathetic stimulation. Parasympathetic control of the detrusor is supplied by which
of the following nerves?
A. Hypogastric nerve
B. Pudendal nerve
C. Peroneal nerve
D. Pelvic nerve
E. Sciatic nerve

19. A 33-year-old G3P2012 woman presents to your office with a complaint of absent menses for the
past 6 months. She has a history of tubal ligation, and did a urine pregnancy test earlier that
morning, which was negative, and further, she states that she is not sexually active. She has noted
that she has been increasingly fatigued lately, and has noted that her hair has become more brittle
and coarse, and she seems to be losing more hair than usual in the shower and on her hairbrush.
She attributed many of these symptoms to stress at home related to recent separation with her
husband as well as feeling exhausted chasing after her two young children. She denies any other
medical problems, and other than the tubal ligation, has had no surgeries. She does note that she
breastfed for 6 months after her most recent child without difficulty. She takes only occasional
ibuprofen for a headache and a multivitamin. She denies allergies to medication. On physical
examination, you note a heart rate of 58, normal blood pressure. Her skin is notably coarse and
dry, but otherwise your examination is unremarkable. You perform a series of laboratory studies
including a urine pregnancy test, complete blood count, prolactin, FSH and estradiol, and thyroid
function testing. All are normal with the exception of her TSH, which is markedly elevated, and T4,
which is low. You recommend treatment with T4 replacement. She is hoping to have another
pregnancy sometime in the future and wonders about how the medication will affect her pregnancy.
You inform her that:
A. She will need less thyroid medication during pregnancy
B. She will be able to stop her thyroid medication in pregnancy
C. Her thyroid medication will not need adjustment because the fetus autoregulates its own thyroid
D. She will need more medication during her pregnancy
E. The dose of her thyroid medication will be tripled upon confirmation of pregnancy and will
continue at the same dose throughout gestation

20. A 37-year-old G7 P6 with a dichorionic/diamnionic, vertex/vertex twin gestation at 38 weeks

presents to labor and delivery for induction of labor. She is started on oxytocin and begins having
contractions after several hours. The patient progresses slowly over the next 16 hours until she is 5
cm dilated and, at this point, develops a fever and fetal tachycardia. The woman is diagnosed with
chorioamnionitis and antibiotic therapy is started. She delivers the babies vaginally 6 hours later.
Right after delivery of the second infant, there is a large, continuous hemorrhage from the vagina.
The most likely cause of this is:
A. vaginal laceration.
B. cervical laceration.
C. uterine atony.
D. uterine rupture.
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E. placenta accreta.

21. A 25-year-old G1P1 woman presents to urgent care with a 4-day history of suprapubic pain,
increased urinary frequency, burning with urination, and increased vaginal discharge. She reports a
history of similar symptoms 1 month ago when she was treated empirically for a urinary tract
infection. All of the following are appropriate in the management except?
A. Administer trimethoprim-sulfamethoxazole PO twice daily for 3 days
B. Send urine specimen for urinalysis
C. Send urine specimen for urine culture
D. Perform microscopy of the vaginal discharge
E. Perform NAAT for Chlamydia and gonorrhea

22. A 29-year-old G0 has been a type 1 diabetic for 17 years and now presents for pregestational
counseling. In addition to the standard pregestational advice such as checking a rubella titer and to
take folic acid, you counsel her regarding tight blood sugar control prior to becoming pregnant.
Assuming that the patient lowers her HgbA1c prior to pregnancy, the risk of which of the following
complications will be unchanged?
A. Caudal regression syndrome
B. Cardiac anomalies
C. Fetal macrosomia
D. Neural tube defects
E. All of the above

23. A 13-year-old girl presents with severe lower abdominal pain of 24 hours’ duration. She states that
the pain is sharp and constant and that she has had similar pain for several days, approximately
every month over the past 4 months. She has no vomiting or diarrhea with the pain, but she is
constipated frequently, having a bowel movement about every 3 to 4 days. She feels that her jeans
are getting tighter around the waist, although she remains active, playing soccer daily. She has
never had a menstrual period and denies ever being sexually active. She has normal vital signs,
normal stature, Tanner stage 3 breast development, and Tanner stage 3 pubic hair. Abdominal
examination reveals a firm and tender midline mass that is inferior to the umbilicus. The patient
refuses a pelvic examination, but agrees to a visualization of the vulva; when parting the labia
minora, a tense bulging membrane can be seen. Of the following, the most likely diagnosis is
A. Pregnancy
B. Fibroid uterus
C. Hematocolpos
D. Endometriosis
E. Ovarian cyst

24. Your next patient in clinic is a young woman who recently underwent a dilation and evacuation of
the uterus for acomplete molar pregnancy. She is now being followed with weekly β-hCG levels to
monitor for recurrent disease.Initially, her β-hCG levels declined. Unfortunately, the levels then
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plateaued and, 8 weeks after evacuation, began torise. They have continued to rise over the past
2 weeks. The patient has not been sexually active since the evacuation and has been reliably
taking oral contraceptive pills. You inform her of the rising levels and your suspicion of
apersistent/invasive molar pregnancy. The evaluation for metastatic disease is negative. Together
you make a plan for her follow-up care. How do you manage her disease at this stage?
A. Continue expectant management
B. Repeat D&C
C. Total abdominal hysterectomy
D. Single-agent chemotherapy
E. Multiagent chemotherapy
25. A 20-year-old African American G2P2 is seen in the hospital on postpartum day number 1, after a
spontaneous vaginal delivery of a healthy male infant with APGAR score of 8 and 9. Her pregnancy
was uncomplicated. Her delivery was complicated only by a second degree perineal laceration that
was repaired in standard fashion. Her medical history is significant for having Hepatitis C. She also
reports a history of breast augmentation. She received an intramuscular injection of Depo-Provera
for postpartum contraception. This morning she appears very tired and although doing well from a
physical standpoint is noted to be bottle-feeding her infant. She acknowledges the benefits of
breast-feeding but explains that bottlefeeding has its merits as well. Which of the following
describes one of the benefits of bottle-feeding over breast-feeding?
A. She decreases her risk of vertical transmission of Hepatitis C by bottle-feeding
B. She will be unable to breast-feed because of her history of breast augmentation
C. Breast-feeding is contraindicated in women receiving Depo-Provera for contraception
D. Bottle-feeding ensures a more adequate supply of milk to her baby during the first few days of
life
E. Breast-feeding may not provide enough Vitamin D for some infants compared with that
supplemented in formula

26. A 42-year-old G3 P3 comes in to see you for a second opinion. She has had fibroids all of her life
but her periods have always been regular and she has never had postcoital spotting or
intermenstrual bleeding until recently. Over the past year or so her periods have become very
heavy with more cramping and she also had some prolonged menses lasting 7 to 10 days (normal
for her is 4 days). She is sexually active with her husband but had a tubal ligation after their last
child was born. Her TSH was normal and her β-hCG was negative. Her FSH level showed her to be
premenopausal. Her pelvic ultrasound showed an 8-cm uterus with two 2-cm intramural fibroids.
There was thickening of the junction between the endometrium and myometrium up to 15 mm in
some locations. The junction was indiscernible in other places. Her ovaries were both normal. This
was confirmed on pelvic MRI. Her primary gynecologist has suggested that she may need a
hysterectomy and she wants your opinion. In this situation, the patient's symptoms would best be
treated with:
A. total abdominal hysterectomy and bilateral salpingooophorectomy.
B. hysteroscopic myomectomy.
C. abdominal myomectomy.
D. total abdominal hysterectomy.
E. vaginal hysterectomy.

27. An otherwise healthy 32-year-old G5 P3013 presents for her first prenatal visit at 8 weeks'
gestation. She had a spontaneous miscarriage 9 years ago before having two term vaginal
deliveries 7 years ago and 5 years ago before undergoing a cesarean section 2 years ago. You
request the operative note from that procedure. Which of the following would be an absolute
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contraindication for a trial of labor after cesarean and attempt at vaginal birth after cesarean
(VBAC)?
A. A classical cesarean section for transverse presentation
B. An emergent low-transverse cesarean section for nonreassuring fetal status
C. A low-vertical cesarean section for cephalopelvic disproportion
D. A scheduled low-transverse cesarean section for active herpes simplex lesions
E. A low-transverse cesarean section for breech presentation

28. A 35-year-old G4P0030 presents to the office for her initial prenatal visit. She is 8 weeks pregnant,
dated by her last normal menstrual period. Her obstetric history is significant for an elective
termination of pregnancy as a teenager, and two losses at 16 weeks’ gestation in the past 3 years.
With both of her later pregnancy losses, she reports that she presented to the hospital with mild
spotting, was found to be 4 to 5 cm dilated, and delivered very shortly thereafter. Genetic analysis
of both fetuses was normal. Her medical history is significant for a history of cervical dysplasia
leading to a LEEP procedure at age 27. She denies any history of bleeding or clotting disorders.
She is in a monogamous relationship, and her current partner is also the father of her two most
recent pregnancies. This is a highly desired pregnancy. What recommendation would you give this
patient?
A. She and her husband should undergo karyotyping to look for a balanced translocation
B. She should have a hysterosalpingogram after this pregnancy to look for uterine abnormalities
C. She should undergo chorionic villus sampling (CVS) to evaluate the chromosomes of the fetus
D. She should start progesterone supplementation for presumed luteal phase defect
E. She should have a prophylactic cerclage placed between 12 and 14 weeks for presumed
cervical incompetence

29. A 21-year-old G0 presents for her first gynecologic exam. She states that she is not sexually active
and is a virgin. She is a college senior who plays volleyball on the club team and has no significant
medical history. She has regular menses with some mild dysmenorrhea. On speculum exam, you
observe a small raised lesion 0.5 cm in diameter on the face of the cervix. It is smooth and blue in
color with the appearance of a bubble underneath the cervical surface. What is your diagnosis?
A. Bartholin cyst
B. Nabothian cyst
C. Skene's gland cyst
D. Cervical dysplasia
E. Cervical cancer

30. A 25-year-old G1 at 9 weeks’ GA comes to her initial prenatal visit, and in addition to a series of
blood tests, a screening urine culture is obtained. She is asymptomatic and asks why this additional
test must be performed. You counsel her that:
A. Even though she is asymptomatic, she is still at risk for STIs and this is one way to screen for
those types of infections
B. Asymptomatic bacteriuria if not treated has been associated with higher rates of
chorioamnionitis and neonatal sepsis
C. She is at increased risk of having asymptomatic bacteriuria compared to nonpregnant patients
D. Asymptomatic bacteriuria increases her risk of cystitis, pyelonephritis, and preterm birth
E. You are worried that she has pyelonephritis
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31. Your next patient is a 34-year-old who was diagnosed with endometriosis 10 years earlier. She and
her husband have been unable to conceive after 1.5 years of unprotected intercourse. Which of the
following is most likely to improve their chance of conceiving?
A. NSAIDs
B. Oral contraceptive pills
C. Oral medroxyprogesterone acetate
D. Depot Lupron with add back therapy
E. Surgery for lysis of adhesions and fulguration of endometriosis

32. A 35-year-old G0 woman presents to your office with complaints of bloody nipple discharge from
the left breast. She is most distraught. Her mother was diagnosed with breast cancer at age 45.
When asked about breast self-examination, she denies feeling a mass at home but states she is
also not very consistent in examining herself. You perform a breast examination, collect some of
the discharge, perform a guaiac test, and then send it for cytology. The most likely diagnosis
associated with her nipple discharge is:
A. Physiologic discharge
B. Fibroadenoma
C. Cystosarcoma phyllodes
D. Intraductal papilloma
E. Invasive papillary carcinoma

33. A 25-year-old nulliparous female presents to her gynecologist with chief complaint of infertility. She
states that she and her husband have been trying to get pregnant for the past year. She has
regular periods that she considers somewhat heavy associated with cramping pain during the first 2
to 3 days of her menses. She undergoes a hysterosalpingogram which confirmed tubal patency but
demonstrated an irregular uterine cavity surface consistent with submucosal leiomyomata (fibroids).
Considering this patient's desire for a pregnancy, what is the most appropriate treatment for her
fibroids?
A. Uterine artery embolization
B. Combined oral contraceptives
C. Depot medroxyprogesterone
D. Hysteroscopic myomectomy
E. Total hysterectomy

34. A 19-year-old woman presents with complaints of no periods for the past 7 months. During this time
she startedcollege and feels her stress level has increased. The patient has also changed her
eating habits, which has led to aweight decrease from 120 to 105 pounds. She has noted no other
changes in her health. Which of the following tests should be ordered initially?
A. TSH, prolactin
B. β-hCG, prolactin, TSH
C. FSH, β-hCG
D. Prolactin, β-hCG, DHEAS
E. Testosterone, β-hCG

35. The labs ordered for the patient discussed above were all normal. Which of the following would be
the best way to assess this patient's estrogenization?
A. Progesterone challenge test
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B. ACTH stim test

C. LH/FSH ratio
D. Estradiol levels
E. Endometrial biopsy

36. A common complication of both epidural and spinal anesthesia includes:

A. Maternal hypotension
B. Maternal hyperventilation
C. Fetal tachycardia
D. Tetanic uterine contractions
E. Chorioamnionitis

37. A 64-year-old G2 P2 presents for her annual examination. She complains of abdominal bloating
and has noted some difficulty zipping her pants despite a recent unplanned 10-lb weight loss. She
has also noticed copious watery vaginal discharge, often preceded by a sharp pain in her LLQ. This
complex of symptoms is suspicious for what condition?
A. Epithelial ovarian cancer
B. Germ cell
C. Dysgerminoma
D. Fallopian tube cancer
E. Endometrial cancer

38. A 17-year-old G1 presents in term labor and progresses to complete dilation and +3 station. She
pushes for 2hours and progresses to +4 station but cannot deliver the fetal head. Which of the
following is a theoretical benefit to performing a mediolateral episiotomy compared to a median (or
midline) episiotomy?
A. Less painful for patient
B. Decreased risk of infection
C. Ease of repair
D. Decreased risk of fourth-degree laceration
E. Improved healing

39. A 17-year-old G1 P0 patient presents to your office with vaginal bleeding at approximately 8 weeks’
gestation by her last menstrual period. Her examination is benign with a 10-week-sized uterus, a
closed cervical os, and a small amount of blood within the vaginal vault. You order a complete
pelvic ultrasound that shows an intrauterine gestational sac containing a fetus measuring
approximately 6 weeks’ gestation. Doppler sonography is unable to demonstrate any fetal
heartbeat. The placenta demonstrates marked thickening and increased echogenicity with
scattered cystic spaces within the placenta. A serum β-hCG is 52,000 mIU/mL. What is the most
likely diagnosis?
A. Complete molar pregnancy
B. Incomplete molar pregnancy
C. Incomplete abortion
D. Missed abortion
E. Inevitable abortion

40. A 21-year-old G1P1001 is now 36 hours status post a primary low transverse cesarean section for
failure to progress after a prolonged attempt at a vaginal delivery. She is complaining of abdominal
pain that is worsening. Her temperature is 38.5°C, BP is 115/70 mm Hg, P 106, O2 saturation of
97%, and respirations are 16. Her uterine fundus is exquisitely tender to palpation. Lungs are clear
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to auscultation, no signs or erythema or tenderness of the breasts, and she has no swelling or pain
in her lower extremities. There is no incisional erythema or induration. Labs reveal a WBC of 22
and hematocrit of 34. What is the most appropriate next step to evaluate and treat this patient?
A. CT of the abdomen and transfuse 2 units of packed RBCs.
B. Do nothing as these are all normal findings after a cesarean delivery.
C. Culture for Gonorrhea and Chlamydia and treat with azithromycin.
D. Perform a bimanual exam and start IV clindamycin and gentamycin.
E. Dopplers of the lower extremities and start heparin or lovenox

41. A 25 yo G1 with a singleton pregnancy at 27 weeks' gestation presents to labor and delivery with
contractions and vaginal spotting. External tocometry demonstrates regular contractions every 3 to
4 minutes, and her cervical exam is 3 cm dilated. Fetal heart rate monitoring is reassuring. She is
initiated on tocolysis in order to achieve steroid benefit. Which of the following is a tocolytic whose
mechanism of action is to directly block the influx of calcium into smoothmuscle cells?
A. Indomethacin
B. Nifedipine
C. Magnesium sulfate
D. Betamethasone
E. Terbutaline

42. A 37-year-old patient reports lifelong oligomenorrhea with limited previous evaluation. Her last
menstrual period was 10 months ago. She does bring images and report of a recent outside
ultrasound that is negative for any anatomic pathology. Her physical examination is significant for
obesity (BMI 43) and moderate facial hirsutism, but no other signs of hyperandrogenism. She does
not have any other significant comorbidities. What is the most likely diagnosis?
A. Congenital adrenal hyperplasia
B. Androgen producing tumor
C. Conn syndrome
D. Polycystic ovary syndrome
E. Anabolic steroid administration

43. A 17-year-old gymnast presents in generally good health except for the absence of menses. She
states that she developed breasts later than her friends and never began menstruation. On
physical examination, she has Tanner stage V development of breasts and pubic hair. On
speculum exam, her cervix appears normal and she has a normal bimanual exam. The most likely
etiology of this patient's primary amenorrhea is:
A. anorexia nervosa.
B. gonadal agenesis.
C. transverse vaginal septum.
D. testicular feminization.
E. hypogonadotropic hypogonadism.

44. A 30-year-old G0 comes in for her annual examination and tells you that she plans to become
pregnant sometime in the next year. She had a LEEP procedure 7 years ago at another facility for
moderate dysplasia, CIN II. She states her Pap testing has been negative since the LEEP and her
last pap was 3 years ago, but you do not have any records documenting these results. Her Pap test
returns high-grade squamous intraepithelial lesion (HSIL) and she is high-risk HPV positive. You
have her return for colposcopy. After the application of acetic acid, you see a large, dense, white
area with mosaic vessels encompassing the entire anterior cervix and extending into the
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endocervical canal. You obtain a biopsy of this area and perform an endocervical curettage. The
pathology report for the biopsy and ECC are both CIN III. What treatment do you recommend?
A. LEEP in office
B. Cryotherapy in the office
C. LEEP in OR
D. Simple hysterectomy
E. Radical hysterectomy

45. A 16-year-old female presents to your clinic with primary amenorrhea. She is not sexually active
and to confirm you check a pregnancy test which is negative. She had normal breast development
that began at age 12 and is now at a Tanner stage V. Pelvic exam reveals a blind pouch that
represents a very shortened vagina. Abdominal ultrasound reveals bilateral normal appearing
ovaries and a pelvic mass consistent with a uterus. Chromosome analysis reveals that she is 46,
XX. Which is the most likely diagnosis?
A. Testicular feminization
B. Gonadal agenesis
C. Mayer-Rokitansky-Kuster-Hauser syndrome
D. Swyer's syndrome
E. Turner's syndrome

46. A 68-year-old woman presents with vulvar pruritis for the prior year that has been increasing over
the past few months. She has tried antifungal medications, which seem to help but the symptoms
always return and have persisted for several months. She went through menopause at age 49 and
has not been sexually active for 10 years. She does not use douching products and is not on any
antibiotics. On physical examination, you note thin white epithelium of the labia, perineum, and
perianal area which is consistent with lichen sclerosis. How do you proceed?
A. Wide local excision of the lesion
B. Perform a punch biopsy of the vulvar lesion
C. Use cryotherapy to eradicate the lesion
D. Culture the vagina and treat with a long course of antifungals
E. Treat with moderate-potency topical steroids

47. Your next patient is a 28-year-old African-American female with a history significant for a renal
transplant 3 years ago. She presents to the clinic for a colposcopy for further evaluation of an high-
grade squamous intraepithelial lesion (HSIL) Pap test. On colposcopic examination, there were no
lesions seen or identified on her cervix. She returns 6 months later for another repeat Pap test,
which remains HGSIL. On colposcopic examination, her results are satisfactory, and she continues
to have no colposcopic changes on her cervix. You have performed an ECC and examination of the
vagina. In the posterior vaginal fornix, you note a single acetowhite lesion with punctation. Your
next recommendation is to:
A. Biopsy
B. 5-FU
C. Loop electrosurgical excision procedure conization of the cervix
D. Wide local excision
E. Laser vaporization

48. A 44-year-old woman comes in with a complaint of unilateral bloody nipple discharge. On
examination in your office there is no skin change, nipple discharge, enlarged lymph nodes, or
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tenderness. There is no mass on clinical breast exam and she has no known family history of
breast cancer. A mammogram and ultrasound are both negative.The most likely diagnosis is:
A. intraductal papilloma.
B. mammary duct ectasia.
C. Paget disease of the breast.
D. carcinoma in situ.
E. invasive breast cancer.

49. A 23-year-old G1 P0 at week 38 is being managed with magnesium sulfate while she undergoes
induction of labor for severe preeclampsia. She received a 4-g bolus followed by a constant
infusion of 1.0 g/hr. However, the nurse found the patient to have absent patellar reflexes and a
respiratory rate of 6 breaths/minute. The patient can be aroused but is very drowsy. In addition to
discontinuing the magnesium, what should your next management step be?
A. Administer terbutaline
B. Intubate immediately
C. Administer calcium gluconate
D. Give betamethasone
E. Do nothing further

50. A 26-year-old G2P2 woman presents for a routine examination. Her physical examination is entirely
normal; however, her Pap smear shows atypical squamous cells of undetermined significance
(ASCUS). Her high-risk HPV screen is positive. You explain the results to the patient and
recommend that she have a colposcopy. Subsequent colposcopy reveals a lesion on the anterior
aspect of the cervix. The transformation zone is entirely visualized. The lesion turns white after
treatment with acetic acid and both punctations and mosaicism are noted. The cervical biopsyis
read as moderate dysplasia (CIN II). Which of the following is the standard of care for management
of this patient?
A. Imiquimod (Aldara) treatment
B. Cryotherapy
C. Cold-knife cone biopsy
D. Loop electrosurgical excision procedure (LEEP)
E. Simple hysterectomy

51. A 27-year-old woman presents to the emergency department complaining of vaginal discharge and
abdominal pain. On physical examination she has a temperature of 38.1°C and on abdominal exam
has tenderness in the right upper quadrant and lower abdomen with minimal peritoneal signs. On
speculum exam, the patient has a mucous yellow discharge. On bimanual exam, she has cervical
motion tenderness and bilateral adnexal tenderness. Her whiteblood cell count is 14.3 and a pelvic
ultrasound shows a normal uterus and normal ovaries bilaterally. The most likely diagnosis for this
patient is which of the following?
A. Cervicitis
B. Endomyometritis
C. Pelvic inflammatory disease
D. Tubo-ovarian abscess
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E. Appendicitis

52. A 29-year-old G0 woman presents for a routine examination. Her physical examination is entirely
normal;however, her Pap smear shows a high-grade squamous intraepithelial lesion (HSIL). She is
otherwise healthy and is amoderate smoker. You perform an immediate colposcopy and the
biopsies read as squamous cell carcinoma in situ (CIS). The patient would like to preserve her
fertility if possible. How would you manage this patient?
A. Simple hysterectomy
B. Cryotherapy
C. Loop electrosurgical excision procedure
D. Radical hysterectomy
E. Cold-knife cone biopsy

53. Your next patient is a 43-year-old G2 P1 Caucasian female who comes in to see you for involuntary
loss of urine. Her history is notable for a radical hysterectomy and bilateral salpingo-oophorectomy
for cervical cancer. Unfortunately, she had a recurrence of her cancer but it was controlled with
pelvic radiation. She is feeling well but is concerned about constantly leaking urine. The leaking is
painless but continuous. When methylene blue is instilled into the bladder in a retrograde fashion,
there is no blue leakage onto the vaginal tampon. However, when indigo-carmine is intravenously
administered, the dye leaks onto the tampon. What is the most likely source of this patient's
incontinence?
A. Urethrovaginal fistula
B. Vesicovaginal fistula
C. Ureterovaginal fistula
D. Overflow incontinence
E. Genuine stress urinary incontinence

54. A young couple comes in with a chief complaint of infertility. The patient is a 30-year-old G0 who
has not undergone any evaluation. Her husband is 33 years old, has had a semen analysis, which
was reported as normal. He has never fathered a child. The couple reports having unprotected
intercourse for the past 14 months. On further history, the patient reports that her periods have
been quiet irregular over the last year and that she has not had period in the last 3 months. She
also reports hot flashes, vaginal dryness, and decreased libido. The patient’s FSH level is 40
mIU/mL, and the estrogen level is less than 20 pg/mL. You repeat the lab tests in 4 weeks, and the
findings are similar. You have the patient and her husband come back to clinic and gently give
them the diagnosis. They have many questions of what this means in terms of their ability to
achieve a pregnancy. You let them know that their best chances of achieving a pregnancy are with
A. Gonadotropins/intrauterine insemination (IUI) therapy
B. In vitro fertilization (IVF) with the patient’s own eggs
C. IVF with donor eggs
D. There is no way for this patient to carry a pregnancy given the diagnosis
E. Ovulation induction (OI) with aromatase inhibitors

55. A 61-year-old postmenopausal female presents for her annual exam without complaints. You notice
a white patchy area between the posterior forchette of the vagina and the anus. When questioned
about this area, the patient denies any pruritis or irritation. You obtain a biopsy of this area, and the
pathology report diagnoses lichen sclerosis. What is the first line treatment for this lesion?
A. Wide local excision
B. Clobetasol cream
C. Laser vaporization
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D. Topical antifungals
E. Topical estrogen cream

56. A 24-year-old G2P1001 female is diagnosed with fetal anencephaly, a lethal anomaly, at her first
prenatal visit at 16 weeks. She is otherwise healthy. She had a previous term vaginal delivery
without complications. She wishes to terminate this pregnancy. Which termination method has the
lowest maternal mortality rate at this gestational age?
A. D&E
B. Labor induction
C. Medication abortion
D. Manual vacuum aspiration
E. D&C

57. A 52-year-old menopausal patient comes in for a complaint of involuntarily leaking urine. These
episodes occur without warning and may happen any time during the day or night. The leaking
occasionally occurs with coughing or laughing but there is no clear association between her leaking
and any specific activity. Occasionally, if she even sees a bathroom, she feels the urge to void. This
has become more and more of a problem for her since she has an active work life and social life.
You perform some simple tests in your office and send her for further urodynamic testing. Her
physical exam is largely unremarkable. Her urinalysis and cultures are negative. Urodynamic
evaluation shows the presence of spontaneous bladder contractions even after filling the bladder
with small amounts of fluid. What treatment would you offer this patient?
A. Bladder suspension/sling procedure
B. Vaginal pessary
C. Kegel exercises
D. Anticholinergics
E. Anterior colporrhaphy

58. A 23-year-old F G0 comes to your office to discuss an effective method of contraception. Her only
medical condition is endometriosis—diagnosed by laparoscopy 3 years ago. She was placed on
oralcontraceptives shortly after her laparoscopy and fulguration of endometriosis. Unfortunately,
she lost her health insurance after the surgery and was not able to refill the medication. She has
not resumed care until now. She has been sexually active with the same partner for 3 years and
has monthly menses with moderate flow. She has never had an STI and is not planning to become
pregnant in the near future. You tell her that the mechanism of action of oral contraceptives
includes:
A. Thickening of cervical mucous
B. Making the endometrial environment unsuitable for implantation
C. Interfering with pulsatile FSH/luteinizing hormone (LH) surges
D. Suppressing ovulation and follicular recruitment
E. All of the above

59. A 31-year-old obese woman presents to your office for an infertility consultation. She and her
husband have been attempting pregnancy for the preceding 18 months. She states that her
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menses are irregular, occurring every 25 to 47 days, and sometimes she skips menses altogether.
They are sometimes heavy, other times light with just brown spotting. She notes that her menses
have always been this way, ever since menarche at age 12. She denies any history of sexually
transmitted infections, and her husband has proven paternity with a previous wife. She notes that
she has never been pregnant. On further questioning, she admits to plucking and shaving
excessive hair from her chin, around her navel, and on her lateral thigh. She also admits to
bothersome acne and extreme difficulty with weight loss. Physical examination reveals obesity with
BMI 31, normal breast development, and the presence of excessive hair as described by the
patient. Pelvic examination reveals normal. What test might you perform to determine whether this
patient is ovulatory in any given month?
A. Urinary ovulation predictor kits
B. Day 3 progesterone
C. Day 28 progesterone
D. Luteal phase endometrial biopsy external genitalia and unremarkable bimanual examination.

60. A 27-year-old G0P0 woman presents to your office with a history of amenorrhea. She has a history
of infrequent menstrual cycles in high school but she had regular withdrawal bleeds in college and
medical school while on oral contraceptive pills. She stopped her birth control pills about 7 months
ago and her period never resumed and she developed mild hirsutism along with a 10 lbs weight
gain. She is sexually active with a male partner and uses condoms for contraception. She has a
history of seasonal allergies, no prior surgeries, and no prior pregnancies. Additional significant
history that you might want to ask about includes:
A. the type/brand of oral contraception she was taking
B. her typical diet and exercise pattern
C. family history of amenorrhea
D. age at first coitus
E. does she desire future fertility

61. A 32-year-old G1P1001 woman presents to your office with the chief complaint of amenorrhea
because her most recent vaginal delivery 1 year ago. She notes that she had an uncomplicated
pregnancy, followed by the delivery of a healthy baby boy. Her delivery was complicated by an
intraamniotic infection as well as a postpartum hemorrhage requiring a postpartum dilation and
curettage (D&C). After her delivery, she breastfed for 6 months, and during this time, she had scant
and irregular vaginal bleeding. After stopping breastfeeding 6 months ago, she notes the absence
of menses, but instead has monthly painful cramping, which seems to be getting worse. She
remarks that prior to her pregnancy, she had normal, regular menses, which were not too heavy or
painful. She and her husband would like to have another child, and have been having unprotected
intercourse for the last 6 months without achieving a pregnancy. Your review of systems is
otherwise negative. You perform a physical examination, which is normal other than a slightly
enlarged, tender uterus. A urine pregnancy test in the office is negative. What is the most likely
diagnosis?
A. Sheehan syndrome
B. Lactational amenorrhea
C. Asherman syndrome
D. Primary ovarian insufficiency (POI)
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62. You are seeing a 23-year-old G0P0 who is interested in obtaining more information on available
contraceptive methods. She is a nonsmoker who has had chlamydia once in the past. She has had
four male sexual partners in the past and uses condoms intermittently. Her family history is notable
for postmenopausal breast cancer in her mother, who was recently diagnosed and is doing well.
She denies any family history of endometrial, colon, or ovarian cancer. The patient wants to know if
she is a candidate for oral contraceptive pills. You tell her that the absolute contraindications for the
use of estrogen-containing oral contraceptives include:
A. a history of migraine headaches.
B. a history of pulmonary embolism.
C. current smoking.
D. symptomatic fibroid uterus.
E. current hypertension.

63. Of the following, which classic triad characterizes preeclampsia?

A. Visual changes, proteinuria, pitting pedal edema
B. Headache, visual changes, right upper quadrant pain
C. Hypertension, visual changes, right upper quadrant pain
D. Hypertension, proteinuria, and nondependent edema
E. Hypertension, proteinuria, and pitting pedal edema
64. A 28-year-old patient is in your office to discuss the possibility of getting pregnant. As part of her
history, you take thorough menstrual history. She states that she had menarche at age 12 years.
Initially, her menses was irregular, but since she was 14 years, her menses has been every 30
days and last for 5 days. She uses four to five tampons a day and denies dysmenorrhea. The
menstrual cycle is divided into which two phases when describing the endometrium?
A. Follicular and secretory phases
B. Follicular and luteal phases
C. Proliferative and luteal phases
D. Proliferative and secretory phases
E. Atrophic and menstrual

65. A 27-year-old nonpregnant woman comes to the emergency department complaining of a vaginal
discharge. On speculum exam, you observe that she has a mucousy yellow discharge and that her
cervix appears erythematous. On bimanual exam, the patient has cervical motion tenderness, no
uterine tenderness, and no adnexal tenderness. Her temperature is 36.7°C, white blood cell count
is 8.4, and the rest of the vital signs and laboratory results are within normal limits. The treatment of
choice for this patient is:
A. azithromycin 1 g PO for 7 days.
B. doxycycline 100 mg PO BID for 7 days.
C. ceftriaxone 250 mg IM times 1 and doxycycline 100 mg PO BID for 7 days as an outpatient.
D. cefoxitin 2 g IV Q6h and doxycycline PO as an inpatient.
E. ampicillin, gentamicin, and clindamycin IV as an inpatient.

66. A 45-year-old G5P5 woman who had three vaginal deliveries and two caesarian sections
underwent an abdominal hysterectomy for large symptomatic fibroids 3 months ago. On
postoperative day 10, she began leaking urine continuously, even at night. She is wearing adult
diapers (Depends) and protective pads all of the time and sleeps with an additional pad under her
at night. Urinalysis and urine cultures are negative. From this history, you are suspicious that this
patient may have:
A. Overflow incontinence
B. Stress incontinence
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C. Continuous incontinence secondary to a urinary fistula

D. Urgency incontinence
E. Functional incontinence

67. A 52-year-old woman presents with no menses for 10 months, hot flashes, vaginal dryness, and
mood swings. Her medical history is otherwise without complications. Her physical examination is
within normal limits and her thyroid and pituitary function are normal. Her FSH is elevated and her
endometrial biopsy shows inactive endometrium with no evidence of hyperplasia or cancer. She
has no liver or renal dysfunction and has never been diagnosed with cancer or abnormal vaginal
bleeding. How would you counsel this patient regarding the use of combination hormone
replacement therapy?
A. She still has her uterus so she should use progestin therapy alone.
B. She still has her uterus so she should use estrogen and progestin therapy.
C. HRT will increase her risk of osteoporosis.
D. HRT will decrease her risk of breast cancer.
E. HRT will decrease her risk of uterine cancer.

68. A 27-year-old G1 P0 at 40 weeks' gestation presents to labor and delivery with contractions every 6
to 8 minutes. Of the following findings, which is the most worrisome on the fetal heart tracing?
A. Repetitive early decelerations, minimal variability
B. No heart rate decelerations, minimal variability
C. Repetitive late decelerations, absent variability
D. No heart rate decelerations, moderate variability
E. Repetitive variable decelerations, moderate variability

69. A 53-year-old woman presents for counseling and management of her Stage II anterior wall
prolapse. She is only symptomatic on days, when she has engaged in heavy lifting or particularly
strenuous activity. She is morbidly obese and would like to begin a formal weight loss program. She
is curious about management options. Of the following, which do you recommend?
A. Conservative management (may include pelvic floor exercises, weight loss, or pessary)
B. Colpocleisis obliterative procedure
C. Gellhorn space occupying pessary
D. Round ligament suspension
E. Hysterectomy

70. A 32-year-old primigravid woman at 8 weeks’ gestation presents to establish prenatal care. She
was diagnosed with HIV 6 years ago and is currently on combination antiretroviral therapy (cART).
Four months ago, her HIV viral load was 7,000 copies/mL, and her CD4 count was 850 cells/mm3.
This is a planned and desired pregnancy. What is the best initial treatment for this patient?
A. Continue cART and repeat viral load and CD4 count
B. Add Efavirenz to the current regimen
C. Stop cART and follow CD4 count and start cART only if viral load is less than 500 cells/mm3
D. Start AZT at 36 weeks regardless of viral load and medication regimen
E. None of the above

71. A 27-year-old woman presents for her annual examination and renewal of her oral contraceptive
(OC) pills. Her history and physical examination were unremarkable except for a non-tender 4 × 4
cm enlargement of the left lobe of her thyroid. Which of the following is key in the evaluation of this
finding?
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A. TSH level
B. ultrasound with fine-needle aspirate
C. free T4 and free T3 levels
D. radioactive iodine scan
E. MRI of neck

72. A 28-year-old G4P2 presents in labor at 37 weeks. You examine her and feel the nose and mouth
of the fetus, with the chin closest to the maternal symphysis. She is 5 cm, 100% effaced, 0 station,
external heart tones are reassuring, and EFW is 6½ lb. What should you do?
A. perform a cesarean delivery
B. give an epidural and very gently manually rotate the baby to vertex
C. give low-dose oxytocin until the head rotates to vertex
D. prepare and administer amnioinfusion
E. allow labor to progress
73. A 19-year-old woman (gravida 0, para 0) presents for her annual sports physical. She is 5 ft 10 in.
tall and weighs 110 lb. She states that she has been having this weight for “a while” and attributes it
to being the star forward for her nationally ranked college soccer team. She does note her last
menses was more than 3 months ago. Her urine human chorionic gonadotropin (hCG) is negative.
Which of the following findings would be inconsistent that her presentation is due to athletic
involvement and instead raise the concern of an anorexic disorder?
A. increased exercise tolerance
B. increased physical activity
C. low body weight
D. resting bradycardia and hypotension
E. lanugo hair

74. A 19-year-old G1P0 patient complains of spotting and right-side pain. She had a positive urine
pregnancy test 3 weeks ago. Ultrasound does not identify an intrauterine pregnancy. On la-
paroscopy 125 cc of blood is seen in the pelvis. There is minimal blood from the tube and a small
bit of tissue is recovered floating free in the peritoneal cavity. This pregnancy is likely which of the
following?
A. spontaneous abortion
B. tubal abortion
C. delivery
D. decidual cast
E. Arias-Stella phenomenon

75. During her annual examination, a patient states that she is very concerned about developing skin
cancer due to a strong family history. You instruct her in the components of a skin examination that
involves evaluating a lesion for danger signs for melanoma, which would include which of the
following?
A. consistent dark black pigmentation
B. diameter of 4 mm
C. nonraised surface
D. asymmetry of appearance
E. smooth border
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76. A 28-year-old G3P0AB2 has a quantitative hCG of 2,850. She has spotting and abdominal pain. An
ultrasound shows fluid in the cal de sac and no intrauterine pregnancy. What is the most likely site
of an ectopic pregnancy?
A. ampulla of the fallopian tube
B. external fallopian tube
C. ovarian surface
D. mesosalpinx
E. interstitial portion of the fallopian tube

77. Prior to making the uterine incision during a cesarean section, the surgeon should examine the
uterus to be sure the incision is properly placed. Which of the following situations generally applies
to the uterus during pregnancy?
A. rotates to the right because of the sacral promontory
B. exhibits no rotation
C. rotates to the left because of the sacral promontory
D. rotates to the left because of the sigmoid colon
E. rotates to the right because of the rectosigmoid

78. A pregnant woman at 32 weeks is brought to the emergency department after a motor vehicle
accident with abdominal trauma. The fetus is dead and the mother is in shock. You diagnose an
abruption and go to the operating room with trauma surgeons for a possible C-section delivery. You
find bleeding into the myometrium beneath the uterine serosa. In severe cases, what is the cause
of abruptio placentae?
A. uterine rupture
B. minimal effect on fetal heart rate
C. adnexal torsion
D. uteroplacental apoplexy
E. disseminated intravascular coagulopathy (DIC)

79. An Rh-negative pregnant woman at 18 weeks’ gestation was found to have a titer of 1:32 anti-
Lewis antibodies and no other evidence of sensitization to red-cell antigens. What should your next
step be?
A. perform a repeat blood test at 4 weeks to see if the titer increases
B. plan to give D-immunoglobulin at 28 weeks’ gestation
C. advise termination of pregnancy
D. plan serial amniocentesis, starting at 24–26 weeks
E. plan middle cerebral artery velocity measurements at 24 weeks

80. A 36-year-old woman (gravida 5, para 3, abortus 1) is first seen for her present pregnancy at 21
weeks’ gestation. History and examination are within normal limits. A routine Pap smear is taken,
which returns as high-grade squamous intraepithelial lesion (SIL) [cervical intraepithelial neoplasia
(CIN) III]. What should you do?
A. repeat the Pap smear
B. advise abortion with cone biopsy or hysterectomy in 4–6 weeks
C. perform colposcopy and biopsy
D. wait until after delivery and obtain another smear
E. perform a cesarean hysterectomy with wide vaginal cuff
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81. A 32-year-old woman (gravida 4, para 3) at 38 weeks’ gestation by good dates presents in your
office with painless moderate vaginal bleeding (soaking two pads) after an otherwise uneventful
gestation. The bleeding presently has ceased and no uterine contractions are present; the FHTs
are 140. What is the best course of action?
A. perform a complete pelvic examination
B. reassure the patient and send her home to await spontaneous labor
C. perform an ultrasound
D. admit the patient to the hospital the following morning for induction of labor
E. perform an immediate cesarean section
82. A patient had a prolonged labor requiring a C-section in the setting of chorioamnionitis. She has
continued with spiking temperatures despite antibiotics and a diagnosis of postpartum pelvic
thrombophlebitis is being made. She suddenly complains of chest pain and dyspnea. Which of the
following tests will be most helpful to diagnose a pulmonary embolism?
A. arterial blood gas
B. spiral computed tomography (CT) scan
C. auscultation of the chest
D. chest x-ray
E. electrocardiogram (ECG)

83. A 23-year-old woman with irregular menses complains of facial hair increasing in amount over
several years. She is sexually active but does not wish to conceive. Examination demonstrates
hirsutism, obesity, and hyper-pigmentation of the neck and axillae. The ovaries are bilaterally
enlarged and cystic. A serum testosterone value is 1.2 ng/mL (normal, <0.8 ng/mL). Serum levels
of DHEAS, 17-hydroxyprogesterone (17-OHP), and prolactin are normal. Which of the following is
the best single therapeutic agent for this patient?
A. glucocorticoids
B. Oral combination contraceptive
C. clomiphene citrate
D. antiandrogens
E. gonadotropin-releasing hormone (GnRH) analogue

84. A class C diabetic patient delivers at term. It is important to check her blood sugar levels
immediately postpartum, since there may be a decrease in the insulin requirements of diabetic
patients. This can be partly explained by which of the following?
A. decreased activity
B. decrease in plasma estrogen
C. decrease in plasma progesterone
D. decrease in plasma chorionic somatomammotropin [hCS or human placental lactogen (hPL)]
E. increased food intake

85. A19-year-old woman is seen in the emergency room with a history of amenorrhea for 8 weeks, and
1 week of unilateral adnexal pain. On physical examination, she is found to have a diffuse
tenderness and fullness in the right ad-nexa. Laboratory evaluations reveal a hematocrit that is
roughly normal, and a positive pregnancy test. Which of the following is the most appropriate
imaging modality to establish a diagnosis in this case?
A. transabdominal ultrasonography
B. IV pyelography
C. computed tomography of the pelvis
D. magnetic resonance imaging
E. transvaginal ultrasonography
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86. A 21-year-old G1 now P1 has had a vaginal delivery of a 2,700-g infant. Her labor was complicated
by severe pre-eclampsia. Bimanual massage of the uterus and intravenous oxytocin do not control
her postpartum hemorrhage. What is the next best intervention?
A. B-Lynch suture
B. D&C
C. prostaglandin F2 (PFG2)-alpha
D. Ergotrate
E. packing the uterus

87. A 21-year-old G1P0 patient has made it to second stage after a slightly prolonged active phase.
She has been pushing effectively for 2 hour without descent from 0 station. As you evaluate for
reasons that are preventing descent you check for the positioning of the vertex presentation. This is
important since there is great variation in the diameter of the vertex depending on the positioning
and in turn the fetal ability to negotiate the pelvic axis and descend in second stage. The greatest
diameter of the normal fetal head is which of the following?
A. occipitofrontal
B. subocciputal bregmatic
C. bitemporal
D. biparietal
E. occipitomental

88. A patient after a prolonged second stage delivers the vertex with an immediate turtle sign with the
head retracting against the perineum. McRobert’s maneuver does not affect delivery. Which of the
following would be a helpful maneuver in managing this shoulder dystocia?
A. fundal pressure
B. Wood’s screw maneuver
C. internal podalic version
D. increased maternal pushing effort
E. Ritgen maneuver

89. A 29-year-old woman (gravida 2, para 1) has a rapid labor. Within minutes of her admission, she is
found to be completely dilated, with the vertex at 0 station, and she begins pushing. You are called
by her nurse to evaluate her. Contractions are regular, every 2–3 minutes, and palpated to be
strong. FHTs are approximately 70 bpm. Cervical examination reveals the vertex to be ROP at 0
station with no caput appreciated. Thick meconium is noted. What should be your first step?
A. instruct the patient to ambulate
B. begin amnioinfusion and increase IV fluids
C. await vaginal delivery
D. give terbutaline to stop contractions
E. turn the patient on her side and administer oxygen by face mask

90. During normal pregnancy, which of the following physiologic effects occur?
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A. increased serum corticosteroid-binding globulin and free cortisol

B. increased serum beta-globulins (transport proteins) and decreased triglycerides
C. increased levels of immunoglobulins A, G, and M
D. increased thyroid-binding globulin and iodide levels
E. decreased serum ionized calcium levels and parathyroid hormone (PTH)

91. A 40-year-old nulligravida female pediatrician comes to see you for irregular vaginal bleeding of 1-
year duration. She has not been using birth control and had hoped to conceive. Endometrial biopsy
revealed endometrial hyperplasia. She would like medical treatment and wants to know which
factor is most important in determining premalignant potential. Which of the following is the best
way to advise your patient?
A. age of the patient
B. degree of cystic atrophy
C. persistence of bleeding
D. degree of cytologic atypia
E. thickness of endometrial hyperplasia

92. A 24-year-old primigravida at 36 weeks’ gestation is exposed to chickenpox. She has no history of
varicella. What is the most appropriate next step in the management of this patient?
A. varicella vaccine within 48 hours of exposure
B. immediate serologic testing for varicella, and if negative, administration of VZIG
C. immediate administration of varicella zoster immune globulin (VZIG) and acyclovir
D. IV acyclovir and the varicella vaccine within 96 hours
E. VZIG within 96 hours

93. A woman wishes to know how she can prevent toxic shock syndrome (TSS). Which of the following
would be the most protective?
A. use tampons with high absorbency
B. use pads rather than tampons
C. change tampons often
D. maintain a neutral vaginal pH
E. maintain a high vaginal oxygen content

94. You are examining a 34-year-old woman (gravida 3, para 2) at 38-5/7 weeks’ gestation. She is in
labor (5 cm). There is no fetal part in the pelvis. Ultrasound report notes a transverse lie with the
fetal back toward the maternal legs. Which of the following is the procedure of choice?
A. cesarean delivery
B. expectant management anticipating spontaneous vaginal delivery
C. tocolysis
D. external version
E. expectant management expecting forceps rotation after complete dilation

95. A patient has a profuse, thin, acellular cervical mucus with a high degree of stretchability and a
palmleaf crystallization pattern upon drying. Which of the following situations is compatible with this
finding?
A. the secretory phase of the menstrual cycle
B. on combination birth control pills
C. being postmenopausal
D. preovulatory estrogen surge
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E. second trimester of pregnancy

96. A 21-year-old nulliparous woman presents for preconception counseling. Her history is remarkable
only for having been told her vagina is abnormally shaped. On pelvic examination, there is a
complete longitudinal vaginal septum. She is concerned as to the implications of this regarding
conceiving, continuing the pregnancy and delivery. In the presence of a complete longitudinal
vaginal septum, which of the following is true?
A. delivery is usually difficult
B. the uterus is less likely to be abnormal
C. there is an above-average incidence of urinary tract abnormalities
D. conception is nearly impossible
E. prophylactic cesarean delivery is indicated

97. A couple returns to your clinic after initial evaluation of their infertility condition. Semen analysis
revealed 35 million sperm/mL, 50% motility and 50% normal forms both to 60%.
Hysterosalpingogram demonstrated a normal endometrial cavity with unilateral proximal tubal
obstruction. The female patient has regular menstrual cycles with appropriate basal body
temperature (BBT) rise indicating a 14-day luteal phase. A serum progesterone level was 15.2
ng/mL. A diagnostic laparoscopy showed no adhesions or endometriosis, with bilateral free spill of
dye from her tubes. What is the most appropriate diagnosis in this case?
A. unexplained infertility
B. luteal-phase deficiency
C. male factor infertility
D. oligo-ovulation
E. tubal factor infertility

98. A 35-year-old woman complains of irregular vaginal bleeding and abdominal pain. Her LMP was 8
weeks ago. A laparoscopic tubal fulguration was performed 2 years ago for permanent sterilization.
She wants to know if her symptoms are related to the previous surgical sterilization. The most
appropriate response is to advise her that a known complication of female sterilization is which of
the following?
A. dysmenorrhea
B. anovulation
C. pregnancy
D. irregular bleeding
E. ovarian cyst formation

99. A patient is referred to you from her primary care provider because of the finding of a large cystic
structure in the vagina that prevented visualization of the cervix and the performance of a Pap
smear. The patient notes that her boyfriend had mentioned feeling something there but it did not
hurt so she had not had it checked until she needed an examination to initial OC pills. On
examination, there is a large cyst (5x4 cm) on the lateral vaginal wall. You biopsy the wall of the
cyst for diagnostic confirmation and to decompress the cyst so a Pap can be done. The pathology
returns with the description that the cyst wall is lined with cuboidal, nonciliated epithelium. This type
of cyst is most likely to be which of the following?
A. paramesonephric duct remnants
B. epidermoid inclusion cysts
C. endometrial implants
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D. adenomatous hyperplasia
E. mesonephric duct remnants

100. An unregistered obstetric patient with no prenatal care presents with active labor and a history
consistent with estimated gestational age of 37 weeks and an 8-hour history of spontaneous
rupture of the membranes. She delivers precipitously. About 8 hours after delivery, her infant
develops septic shock, pneumonia, and a positive Gram’s stain is obtained from the infant’s blood.
The clinical picture in this infant is most consistent with which of the following?
A. group B streptococcal infection
B. group A streptococcal infection
C. infant CMV
D. maternal syphilis
E. neonatal gonore