Questions
DIRECTIONS (Questions 1 through 53): For each of the multiple choice questions in this section, select the lettered answer that is the one best response in each case.
1. What is the maximum normal time for the second stage of labor in a primigravida without anesthesia?
(A) 20 minutes (B) 60 minutes (C) 120 minutes (D) 240 minutes
(E) no normal maximum
2. You are asked to consult on a 26-year-old woman (gravida 2, para 1) with a prior cesarean section because of breech positioning. She is at term. The nurse has plotted the labor curve (see Figure 11–1).
What is the initial step in the evaluation and treatment of the most likely cause of this labor curve?
Figure 11-1
(A) administer oxytocin (B) assess pelvic adequacy (C) give sympathetic block (D) rupture membranes
(E) perform cesarean section
3. Which of the following is the most common indication for primary cesarean section?
(A) dystocia
(B) prolapsed cord (C) diabetes
(D) toxemia
(E) malpresentation
4. Preterm rupture of the membranes is most strictly defined as spontaneous rupture at any time prior to which of the following?
(A) a stage of fetal viability (B) the second stage of labor (C) the 32nd week of gestation (D) the onset of labor
(E) the 37th week of gestation
5. You are examining a term patient in the labor and delivery (L&D) suite. Which of the following signs and symptoms is most likely to indicate ruptured membranes?
(A) vaginal pool pH of 6.5
(B) yellow-green color on nitrazine test
(C) ferning on a specimen from the vaginal pool (D) superficial squamous cells in the vaginal pool (E) copious leakage on pants or underwear
6. Which of the following factors tends to increase the average duration of labor?
(A) increasing parity
(B) increasing age of the mother (C) decreasing size of the baby
(D) occiput posterior (OP) position of the baby (E) ambulation
7. A fetus presents in breech position and is delivered without assistance as far as the umbilicus. The remainder of the body is manually assisted by the obstetrician. What is this called?
(A) version and extraction
(B) spontaneous breech delivery (C) partial breech extraction (D) total breech extraction
(E) Pipers to the aftercoming head
8. A 28-year-old G3P2002 patient presents at 38 weeks’ gestation. A fetus was felt to be in breech
position as judged by information gained through Leopold’s maneuvers. The fetus was well down in the pelvis, and the uterus was irritable. Pelvimetry was within normal limits, and the estimated fetal weight was 7ẵ lb and ultrasound confirms a frank breech with a well-flexed head and AFI of 14 cm.
Assuming the provider has adequate experience in each of the following, what would not be offered to the patient as an approach to delivery management?
(A) cesarean section
(B) external cephalic version (C) internal podalic version (D) vaginal breech delivery (E) expectant management
9. Transverse lie in a multipara at term in labor is best treated by which of the following?
(A) external version
(B) internal version and extraction (C) oxytocin induction
(D) cesarean delivery
(E) abdominal support to effect position change
10. A 30-year-old methamphetamine user presents to L&D in active labor. She has had no prenatal care, but says she is 9ẵ months. You check fetal position and feel face and nose. You are concerned,
because the most common associated condition with a face presentation is which of the following?
(A) anencephaly (B) hydrocephaly (C) prematurity (D) placenta previa (E) oligohydramnios
11. A patient has entered spontaneous premature labor at 28 weeks’ gestation. During the vertex delivery, one should do which of the following?
(A) recommend epidural anesthesia to control delivery (B) perform an episiotomy
(C) use prophylactic forceps (D) use vacuum extraction
(E) allow spontaneous vaginal birth
12. A patient becomes suddenly unresponsive during active labor. The absolute diagnosis of amniotic fluid emboli is made by which of the following?
(A) chest pain (B) chest X-ray
(C) amniotic debris in the pulmonary circulation (D) the presence of consumptive coagulopathy (E) electrocardiogram (ECG) changes
13. Which of the following is a contraindication to the use of oxytocin for stimulating labor?
(A) fetal demise
(B) hypertonic uterine dysfunction (C) hypotonic uterine dysfunction (D) twin gestation
(E) estimated fetal weight less than 5 lb
14. In which of the following cases might internal podalic version be indicated?
(A) vertex delivery of the first twin and breech presentation of the second twin (B) term transverse lie with cervix completely dilated and membranes intact (C) double footling breech
(D) impacted shoulder presentation (E) compound presentation
15. A 34-year-old woman (gravida 4, para 3) at 38ẵ weeks whose pregnancy is complicated by gestational diabetes is in labor. The head delivers, but the shoulders do not follow. An efficacious method of delivery for a shoulder dystocia includes McRoberts maneuver. McRoberts maneuver is described as which of the following?
(A) fundal pressure
(B) extreme flexion of the maternal thighs
(C) rotation to an oblique position after delivery of posterior arm (D) strong traction on the head
(E) rotation of the posterior shoulder to the anterior
16. A 29-year-old G4P3003 with three prior C-sections is diagnosed with a placenta accreta at 28 weeks during follow-up ultrasound of a low anterior placental location. When is placenta accreta most likely to cause bleeding?
(A) during the first stage of labor (B) prior to labor
(C) because of consumption coagulopathy (D) after amniotic membrane rupture (E) during attempts to remove it
17. The risk of serious infection transmitted by blood transfusion is greatest for which of the following?
(A) hepatitis C
(B) Creutzfeldt–Jakob disease
(C) human immunodeficiency virus (HIV) (D) syphilis
(E) hepatitis B
18. If blood must be given without adequate cross-matching, what is the best type to use?
(A) AB Rh-positive (B) AB Rh-negative (C) O Rh-positive (D) O Rh-negative (E) A Rh-positive
19. Which of the following factors is associated with small infants?
(A) mothers with untreated gestational diabetes (B) multiparity
(C) large parents (D) maternal smoking (E) postdate pregnancy
20. A 28-year-old G1P0 presents in active labor at term. Her history is remarkable only for a LEEP 4 years prior for HGSIL. The labor was complicated by complete effacement of the cervix and descent of the vertex at +1 station. However, the cervix did not dilate. A dimple may be noted at the external os.
What is this condition called?
(A) uterine dystocia (B) conglutinate cervix (C) cervix condupulare (D) sacculated uterus (E) vasa previa
21. A 26-year-old woman is first seen at 28 weeks’ gestation. Her history and physical are normal except for the presence of a 2-cm posterior cervical leiomyoma. The patient is relatively asymptomatic.
Which of the following is the best management for this patient?
(A) myomectomy at 36 weeks
(B) myomectomy now with steroids and tocolysis (C) progesterone therapy to decrease the myoma size (D) elective cesarean delivery at term
(E) watchful waiting
22. After a low forceps delivery for fetal intolerance, a mother continues to have excessive vaginal
bleeding despite a well-contracted uterus. Which of the following locations is most likely to be the site of a vaginal laceration after an instrumented delivery?
(A) extending off the cervix
(B) anterior upper third under the pubic symphysis
(C) posterior upper third from an incompletely evacuated rectum (D) lateral middle third over the ischial spines
(E) posterior middle third over the coccyx
23. A patient sustained a laceration of the perineum during delivery. It involved the muscles of the perineal body but not the anal sphincter. Such a laceration would be classified as which of the following?
(A) first degree (B) second degree (C) third degree (D) fourth degree (E) fifth degree
24. A 19-year-old primiparous woman develops postpartum hemorrhage unresponsive to oxytocin and uterine massage. Her infant was 8.5 pounds. She has bled 750 cc. What is the most likely diagnosis?
(A) laceration(s) of cervix or vagina (B) placenta accreta
(C) uterine inversion (D) ruptured uterus (E) coagulopathy
25. A woman develops bleeding at 5-cm dilation with fetal distress. You perform a cesarean birth and find a couvelaire uterus. Which of the following causes a couvelaire uterus?
(A) enlargement and invasion by placental tissue into the uterus
(B) uterine, retroflexion, and adherence to the cul-de-sac peritoneum of the uterine serosa (C) a congenital anomalous development of the uterus
(D) intramyometrial bleeding (E) Intrauterine infection
26. Which of the following situations has the greatest risk for the mother and infant?
(A) rupture of an intact uterus
(B) rupture of a previous uterine scar (C) pathologic contraction ring
(D) dehiscence of a uterine scar (E) cervical laceration
Questions 27 and 28 apply to the following patient
A 35-year-old woman (gravida 7, para 5, abortus 1) is in the active phase of labor with the vertex at –1 station. She complains of abdominal pain with the contractions. At the height of one contraction, the pain becomes very intense. Following this intense pain, uterine contractions cease. The maternal systolic BP drops 15 mm Hg.
27. What is the best course of action?
(A) immediately perform a pelvic examination (B) place the patient on her side and reassure her (C) manage expectantly
(D) begin oxytocin
(E) perform an ultrasound
28. On abdominal examination, you discover a firm mass in the pelvis. It does not feel like the presenting fetal part. What is the most likely cause of the firm mass?
(A) the placenta (B) a uterine fibroid (C) the contracted uterus (D) the fetal head
(E) a pelvic kidney
29. A woman without prenatal care in labor at 38 weeks has a breech presentation. As the breech is expelled, a spina bifida is noted. The head does not deliver. With this history, what is the most likely problem?
(A) hydrocephaly
(B) cephalopelvic disproportion (CPD) (C) fetal goiter
(D) missed labor
(E) incompletely dilated cervix
30. Epidural anesthesia is preferable in which maternal condition?
(A) to avoid maternal valsalva with bearing down in mother with previous cesarean section (B) multiple gestation
(C) maternal cardiac disease (D) compound presentation
(E) premature labor with a fetus <28 weeks
31. A patient in labor with a systolic BP of 125 mm Hg has just been given a saddle block. While lying on her back pushing on the delivery table, the level of the block stabilized at T10, fetal heart tones (FHTs) show a bradycardia to 105 bpm. However, her blood pressure drops to 90 mm Hg systolic. Which of the following is the most likely cause of these symptoms?
(A) high spinal block (B) ruptured uterus (C) cardiac failure
(D) amniotic fluid embolism (E) supine hypotensive syndrome
32. Which of the following indications most likely predict a classic cesarean section as opposed to a traditional transverse lower uterine segment cesarean section?
(A) maternal Crohn’s disease
(B) vertical skin incision, unknown previous uterine incision (C) 26-week gestation with a breech presentation
(D) fundal myoma
(E) twins, with the first baby in a breech presentation
33. Which of the following situations would be likely to have the complication of a contracted pelvis?
(A) Marfan’s disease
(B) long-standing maternal drug use
(C) pendulous abdomen in a primigravida (D) morbidly obese multigravida
(E) short maternal stature
34. The pathologic retraction ring of Bandl is most commonly associated with which of the following?
(A) premature labor (B) uterine fibroids (C) obstructed labor (D) precipitate labor (E) multiple gestation
35. You are called to L&D to consult on a 23-year-old primiparous patient. The fetus has been at —2/—1 station for 4 hours with no dilation past 6 cm. Contractions are firm every 5 minutes. FHTs are
reassuring with occasional early deceleration. EFW is 8 lb. You believe her pelvis is adequate. What is the next step?
(A) forceps delivery (B) cesarean section (C) therapeutic rest
(D) intrauterine pressure catheter to determine Montevideo units (E) parenteral analgesics
36. Term labors lasting less than 3 hours are associated with which of the following conditions?
(A) decreased fetal morbidity (B) less maternal morbidity (C) increased fetal morbidity (D) primiparous labors
(E) twins
37. You are delivering a 22-year-old woman’s (gravida 2, para 0010) twin pregnancy at 38 weeks. The first baby is 6 ẵ lb estimated fetal weight and vertex. The second baby is estimated at 6 lb and breech.
In discussing complications of internal podalic version, you discuss which of the following with the patient?
(A) fecal contamination (B) postpartum hemorrhage (C) perineal tear
(D) undiagnosed hydrocephaly
(E) fetal trauma
38. Your patient has been in labor for over 12 hours and has developed a temperature of 101.2°F. Pulse is 110 bpm. The fetal heart rate is 180 with good variability. The labor is progressing adequately. Which of the following is your next step in management?
(A) intravenous (IV) hydration (B) antibiotics
(C) oxytocin
(D) fetal scalp sampling (E) cesarean delivery
Questions 39 and 40 apply to the following patient:
A laboring patient receiving oxytocin for augmentation of labor suddenly clutches her chest in pain.
Amniotic fluid embolus (AFE) is suspected.
39. The initial signs and symptoms occurring with AFE include which of the following?
(A) cyanosis and respiratory distress (B) renal disease
(C) fever
(D) coagulopathy
(E) tumultuous labor and contractions
40. Treatment for AFE may include which of the following?
(A) hysterectomy
(B) oxygen and respiratory support (C) antibiotics
(D) corticosteroids
(E) avoidance of prostaglandins
41. You are checking a 22-year-old primigravida in active labor. Labor has lasted 14 hours. She is 8-cm dilated and at 0 station. As the fetal head has descended, the shape has changed. Which of the following is the most likely etiology?
(A) cephalohematoma (B) molding
(C) subdural hematomas (D) hydrocephalus (E) caput succedaneum
42. A 42-year-old G4P2012 has had a complicated prenatal course due to chronic hypertension and Type 2 diabetes. She also has adult onset asthma made worse with aspirin. Because of worsening
hypertension an induction was initiated. She dilated to 5 cm and then did not progress further over the next 3 hours. Labor dystocia is likely due to which of the following issues?
(A) maternal hypertensive disorders (B) ineffective uterine contractions (C) maternal pulmonary disease (D) hyperglycemia
(E) electrolyte imbalance
43. Certain patients are more likely than others to have uterine atony and hemorrhage after delivery.
Circumstances that predict possible increased bleeding postpartum include which of the following situations?
(A) prolonged labor (B) primigravidas
(C) hypertensive disorders
(D) pudendal anesthesia for delivery (E) obesity
44. You have just delivered an 18-year-old woman (gravida 1, para 0). She is pre eclamptic. Her uterus is soft with moderate-to-heavy bleeding. Examination reveals no laceration. You diagnose uterine atony. Which of the following is the best management option?
(A) 0.2-mg intramuscular (IM) ergonovine (Methergine) (B) 0.2-mg oral ergonovine
(C) 10 units of oral oxytocin
(D) 250 μg prostaglandin F2-alpha orally (E) 20 units of IV oxytocin
45. A 31-year-old healthy woman (gravida 3, para 2) is in labor at 40 weeks’ gestation. Her first delivery was a low transverse cesarean for breech; the second was an uncomplicated VBAC. Her vital signs have been stable. Her epidural is functioning and she is lying on her side. When the cervix was approximately 7-cm dilated and the fetus was at –1 station, she developed tachycardia to 120 and a drop in blood pressure from 115/60 to 70/30. She has become dizzy upon sitting up. FHTs are 130. No bleeding is evident. The hematocrit is reported at 35%. What is your primary diagnosis?
(A) vasa previa
(B) pulmonary embolus (C) chorioamnionitis
(D) supine hypotensive syndrome (E) ruptured uterus
Questions 46 through 48 apply to the following patient:
A 27-year-old G3P3 has delivered a 9.5lb female after a 21-hour labor in which contractions were augmented with oxytocin. The placenta delivered intact. Her perineum has a second-degree laceration.
46. As you begin to repair the perineum, you also have the nurse administer which of the following?
(A) misoprostol per vagina (B) misoprostol per rectum (C) oxytocin orally
(D) prostaglandin F2-alpha IM (E) oxytocin IV
47. After repair of the laceration, the patient continues to bleed heavily. She has lost 350 cc of blood. At this step you should assess uterine tone and do which of the following?
(A) inspect the cervix and upper vagina for lacerations
(B) do a manual exploration of the uterus for retained products of conception (C) do a bedside ultrasound to evaluate for retained products
(D) place a second large bore IV line (E) place a foley catheter
48. After 45 minutes, the patient has lost 1,400 cc. The uterus is very “boggy” and does not contract well.
Pulse is 105 bpm, blood pressure is 95/58, and oxygenation is 98%. Studies show a hemoglobin of 7.2 with a hematocrit of 22%, a platelet count of 95,000. What should be your next step?
(A) recheck of the hematocrit (B) evaluate for HELLP syndrome (C) prepare for laproscopy
(D) transfer 2 units packed cells and 2 units fresh frozen plasma (E) evaluate for von Willebrand’s disease
Questions 49 and 50 apply to the following patient:
A17-year-old G2P0AB woman with no prenatal care at 29 weeks’ gestation presents with painful contractions and pressure. Her cervix is 3 cm, 60% effaced, and breech at –2 station. There is no evidence of ruptured membranes. Her contractions are every 3 minutes. FHT are 150 with accelerations.
Maternal vital signs are temperature 36.8 degrees, pulse 96, BP 110/72.
49. What should you do?
(A) perform amniocentesis to rule out chorioamnionitis (B) begin tocolytic agents
(C) do a fetal fibronectin
(D) observe to look for cervical change (E) give IV hydration
50. The patient continues to contract, and a repeat pelvic examination is notable for a cervix of 3 cm, 90%. What should you do?
(A) give antenatal steroids (B) start antibiotics
(C) give IV sedation (D) give IV hydration
(E) prepare for a cesarean delivery
51. Match the following fetal heart rate tracing (Figure 11–2) with the descriptive term that best fits the situation.
Figure 11–2. (Reproduced with permission from Cunningham F, et al. Williams Obstetrics, 23rd ed.
New York: McGraw-Hill 2010, p. 418.)
(A) early decelerations (B) late decelerations (C) normal tracing (D) poor variability (E) sinusoidal pattern
Questions 52 and 53 apply to the following patient:
A GP woman at 38 weeks’ gestation presents with contractions of minimal strength but occurring every 2 to 3 minutes lasting 45 to 50 seconds. The FHTs are reactive and reassuring. Her cervix is soft, 1cm dilated, 25% effaced, and the vertex is at —1 station. Her cervix is unchanged since yesterday when she was seen in clinic.
52. With what is this labor pattern is consistent?
(A) prodromal labor
(B) normal uterine wake sleep cycles (C) primary arrest of labor
(D) secondary arrest of labor (E) tachysystole
53. The patient states that she is exhausted and has not slept or eaten in 2 days. Her mother demands that you do something. What is your best plan of management?
(A) admit her to L&D and begin oxytocin
(B) admit her to L&D and begin misoprostol for cervical ripening (C) send her home with reassurance
(D) have her walk for 1–2 hours and recheck
(E) admit and give her medication to rest and for pain
DIRECTIONS (Questions 54 and 55): The following group of questions is preceded by a list of lettered options. For each question, select the one lettered option that is most closely associated with it. Each lettered option may be used once, multiple times, or not at all.
(A) rupture of a classic uterine scar (B) dehiscence of a uterine scar
(C) spontaneous rupture of an intact uterus (D) cervical tear
(E) traumatic rupture of the intact uterus
54. A G5P5 patient develops marked bleeding after delivery of the infant that continues as severe hemorrhage after the spontaneous delivery of the placenta that appears intact on inspection. The bladder is empty. The uterine fundus is firm at the umbilicus. She has an epidural.
55. A 25-year-old G3P2 with prior low transverse cesarean delivery is found to have a paper thin lower uterine segment covered with only peritoneum at the time of a repeat cesarean section. She has no bleeding.
DIRECTIONS (Questions 56 through 59): For each of the multiple choice questions in this section,
select the lettered answer that is the one best response in each case.
56. 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 6ẵ lb. What should you do?
(A) perform a cesarean delivery (B) allow labor to progress
(C) give an epidural and very gently manually rotate the baby to vertex (D) give low-dose oxytocin until the head rotates to vertex
(E) prepare and administer amnioinfusion 57. What position is this baby in (Figure 11–3)?
Figure 11–3. (Reproduced with permission from Cunningham F, et al. Williams Obstetrics, 23rd ed.
New York: McGraw-Hill, 2010, p. 528.) (A) double breech lie
(B) Frank breech presentation
(C) double footling breech presentation (D) complete breech presentation
(E) compound presentation
58. During the induction of labor of a 41.5-week multigravida woman, with misoprostol, the mother begins to feel increasing pelvic pressure and low back pain. FHTs are reassuring and maternal vital signs are p-92, BP 110/68, R-18; T-37 contractions are every 2 to 3 minutes and moderate. Her cervix is 2 cm 50%, —2 station with blood tinged mucus. What does this situation represent?
(A) impending rupture of the uterus (B) normal early labor
(C) tachysystole
(D) misoprostol syndrome (E) primary arrest of labor