ASIPP Pregnancy and Nursing Questions Flashcards
1
Q
1600….weakness of the abductor pollicis brevis, the opponens
pollicis, and the fi rst two lumbrical muscles. Sensation
was decreased over the lateral palm and the volar
aspect of the fi rst three digits. Numbness and tingling
were markedly increased over the fi rst three digits and
the lateral palm when the wrist was held in fl exion for
30 s. The symptoms suggest damage to
A. The radial artery
B. The median nerve
C. The ulnar nerve
D. Proper digital nerves
E. The radial nerve
A
- Answer: B
Explanation:
(Moore, Anatomy, 4/e, pp 775, 821-822.)
The patient has a classic case of carpal tunnel syndrome, in
which the median nerve is compressed as it passes through
the carpal tunnel formed by the fl exor retinaculum in the
wrist. Evidence for involvement of the median nerve is
weakness and atrophy of the thenar muscles (abductor
pollicis brevis, opponens pollicis) and lumbricals 1 to 3.
Sensory defi cits also follow the distribution of the median
nerve. The median nerve enters the hand, along with the
tendons of the superfi cial and deep digital fl exors, through
a tunnel framed by the carpal bones and the overlying
fl exor retinaculum. Symptoms are worse in the early
morning and in pregnancy because of fl uid retention,
resulting in swelling that entraps the median nerve. Flexing the wrist for an extended period exaggerates the
paresthesia (“Phelan’s” sign) by increasing pressure on the
median nerve.
Neither the ulnar nerve, radial nerve, nor radial artery
passes through the carpal tunnel. The ulnar nerve supplies
the third and fourth lumbricals and only the short
adductor of the thumb. The radial nerve innervates mostly
long and short extensors of the digits and the dorsal
aspect of the hand. Proper digital nerves lie distal to the
carpal tunnel but are only sensory.
Source: Klein RM and McKenzie JC 2002.
2
Q
1601. What is the most critical period for fetal exposure to a drug? A. 1st week of pregnancy B. 5th week of pregnancy C. 13th week of pregnancy D. 24th week of pregnancy E. 32nd week of pregnancy
A
- Answer: B
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87)
The most critical period is in the fi rst trimester,
specifi cally weeks 4 through 10 during pregnancy.
Source: Shah RV
3
Q
- An infant born at 35 weeks’ gestation to a mother with
no prenatal care is noted to be jittery and irritable, and
is having diffi culty feeding. Child had coarse tremors
on examination. The nurses report a high-pitched cry
and note several episodes of diaarhea and emesis. It is
suspected that the infant is withdrawing from
A. Alcohol
B. Marijuana
C. Heroin
D. Cocaine
E. Tobacco
A
- Answer: C
Explanation:
Reference: Behrman, 16/e, p 530. Rudolph, 21/e, p 2196.
Infants born to narcotic addicts are more likely than other
children to exhibit a variety of problems, including
perinatal complications, prematurity, and low birth
weight. The onset of withdrawal commonly occurs during
an infant’s fi rst 2 days of life and is characterized by
hyperirritability and coarse tremors, along with vomiting,
diarrhea, fever, high-pitched cry, and hyperventilation;
seizures and respiratory depression are less common. The
production of surfactant can be accelerated in the infant of
heroin-addicted mother.
Source: Yetman and Hormann
4
Q
1603. In which stage of pregnancy do major pharmacokinetic changes of lithium metabolism occur? A. Postpartum and during breast-feeding B. At delivery C. Third trimester D. Second trimester E. First trimester
A
- Answer: B
Explanation:
The maternal lithium level must be monitored closely
during pregnancy and especially after delivery because of
the signifi cant change in renal function with massive fl uid
shift that occurs over that time period. Lithium should be
discontinued shortly before delivery, and the drug should
be restarted after an assessment of the usually high risk of
postpartum mood disorder and the mother’s desire to
breast-feed her infant.
Source: Laxmaiah Manchikanti, MD
5
Q
- True statements about addiction during pregnancy is:
A. The prevalence of substance abuse during pregnancy is
signifi cant
B. Women addicted to drugs always have regular menstrual
cycles
C. Women addicted to drugs are unable to conceive
D. A pregnant woman generally fi nds out that she is pregnant
within a few weeks
E. Less than 2% of pregnant women use illegal substances
during pregnancy
A
- Answer: A
Explanation: - The prevalence of substance use during pregnancy is
signifi cant. In a study of women in a city hospital, 59% admitted to consumption of alcohol during pregnancy. - Women addicted to alcohol or other drugs may have
irregular menstrual cycles, but still be able to conceive. - A study found that 11% of pregnant women were using
illegal substances, with cocaine as the drug of choice in
75%. - It may be several months before an addicted woman
realizes that she is pregnant. - Women of low socioeconomic status are perceived to be
at increased risk of perinatal substance abuse and
addiction, but there is little difference in the prevalence of
drug and alcohol use among women enrolling in prenatal
care in public clinics 16% and private offi ces 13%.
Further, rates for black and white women are virtually
identical (14% and 15%).
6
Q
- A newly delivered mother wants to breast-feed her
healthy infant, but that her obstetrician was concerned
about one of the medicines she was taking. Which
of the woman’s medicines, listed below, is clearly
contraindicated in breast-feeding?
A. Ibuprofen as needed for pain or fever
B. Labetolol for her chronic hypertension
C. Lithium for her bipolar disorder
D. Carbamazepine for her seizure disorder
E. Acyclovir for her HSV outbreak
A
- Answer: C
Explanation:
Reference: Behrman, 16/e, p 460. McMillan, 3/e, p477.
Most medications are secreted to some extent in breast
milk. Some lipid-soluble medications may be concentrated
in breast milk. Although the list of contraindicated
medications is short, caution should always be exercised
when giving a medication to a breast-feeding woman.
Medications that are clearly contraindicated include
lithium, cyclosporin, antineoplastic agents, illicit drugs
including cocaine and heroin, ergotamines, and
bromocriptine (which suppresses lactation). Although
some suggest that oral contraceptives may have a negative
impact on milk production, the association has not been
proven conclusively. In general, antibiotics are safe, with
only a few exceptions. While sedatives and narcotic pain
medications are probably safe, the infant must be observed
carefully for sedation. All of the medications listed in the
question are considered safe, except for lithium.
Source: Yetman and Hormann
7
Q
- During pregnancy, treatment of migraine may include:
A. Ergot/caffeine
B. DHE/Reglan
C. Cafergot
D. Amitriptyline
E. Usually not necessary as migraine frequency and severity
is reduced, and the above-listed drugs are contraindicated
A
- Answer: E
Explanation:
Acetaminophen and meperidine can be recommended for
use during pregnancy; however, any drug presents
potential risk during pregnancy. Aspirin may prolong
labor, cause blood loss during pregnancy, and increase risk
of stillbirth. Ergot may cause placental damage due to
vasoconstrictive effect. Fortunately, migraine tends to
remit during pregnancy. New-onset headache during
pregnancy should be evaluated carefully for potential
vascular or structural lesion.
Source: Neurology for the Psychiatry specialty Board
Review By Leon A. Weisberg, MD
8
Q
1607. Which of the following poses the greatest risk of fetal harm? A. multivitamins B. acetaminophen C. prednisone D. metoprolol E. ergotamine
A
- Answer: E
Explanation:
Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-
87 and
http://www.fda.gov/fdac/features/2001/301_preg.html#cat
egories)
The FDA categories do not necessarily stratify risk, but
actually discuss a risk/benefi t analysis. Note that Category
A and B are probably safe. However, category C and D
drugs may be just as dangerous as category X.
Ergotamines are category X.
Multivitamins are category A.
Acetaminophen, butorphanol, nalbuphine, caffeine,
fentanyl, hydrocodone, methadone, meperidine,
morphine, oxycodone, oxymorphone, ibuprofen,
naproxen, indomethacin, metoprolol, proxetine,
fl uoxetine, prednisolone, prednisone are category B
Aspirin, ketorolac, codeine, propoxyphene, gabapentin,
lidocaine, mexiletene, nifedipine, propanolol, sumatriptan
are category C
Amitriptyline, imipramine, diazepam, phenobarbital,
phenytoin, valproic acid are category D
Source: Shah RV
9
Q
- Anti Infl ammatory medicines are not recommended in:
A. During the process of labor
B. In nursing mothers
C. During pregnancy
D. Those with a history of ulcerative disease
E. All of the Above
A
- Answer: E
Source: Hansen HC, Board Review 2004
10
Q
1609. The most frequent psychiatric disorder of postpartum women is A. An episode of mild schizophrenia B. An episode of mania C. Postpartum “baby blues D. Major depression E. Postpartum psychosis
A
- Answer: C
Explanation:
(Sierles, pp 125-126. Kaplan, pp 27-28,500-501.)
The most frequent (about 50%) postpartum disorder is a
self-limited condition known as postpartum blues, with
rapid swings of mood and irritability, decreased
concentration, and tearing. Next is postpartum major
depression (occasionally mania) in about 10% of
postpartum women, but most severe is postpartum
psychosis (about 1 to 2 per 1000) beginning about 2 to 3
weeks after childbirth. It is still not clear whether
postpartum psychosis is a discrete condition or an affective
or schizophrenia-like condition precipitated by
postpartum stress or endocrine changes. Postpartum
psychiatric disorders respond favorably to treatment and
have a good prognosis, but in all women who experience a
postpartum depression, there is a suicide rate of 5%, an
infanticide rate of 4%, and a recurrence rate of 25% for
postpartum psychosis and depression after subsequent
pregnancies.
Source: Ebert 2004
11
Q
- Studies show that methadone maintenance in the
mother, compared to untreated opioid abusers is
associated with
A. Shorter gestation and increased birth weight
B. Longer gestation and increased birth weight
C. Shorter gestation and decreased birth weight
D. Longer gestation and decreased birth weight
E. All of the above
A
- Answer: B
Source: Raj, Pain Review 2nd Edition
12
Q
- Use of which the following opioids by breast-feeding
mothers via PCA depresses the behavior of the
infant more than the equianalgesic dose of morphine
A. Fentanyl
B. Meperidine
C. Nalbuphin
D. Buprenorphine
E. Tramado
A
- Answer: B
Source: Raj, Pain Review 2nd Edition
13
Q
- This following term describes translating codes from
one system to another (i.e., DSM-IV to ICD-9-CM)
A. encoder
B. prospective payment system
C. crosswalk
D. chargemaster
E. CPT
A
- Answer: C
14
Q
1613. A pregnant patient in the 2nd trimester complains of diabetic peripheral neuropathy. Your drug of choice is: A. Gabapentin B. Mexiletine C. Ibuprofen D. Oxycodone E. Amitripytline
A
- Answer: D
Explanation:
Oxycodone is category B and is considered safe.
Amitriptyline, although generally indicate for diabetic
neuropathy, is category D.
The others are category C.
15
Q
- A 28 African American male presents to the emergency
room agitated and complaining of severe knee pain
and swelling. Urine toxicology screen reveals cocaine.
His mother demands to speak to you and volunteers
that he has sickle cell anemia. Which of the following is
most appropriate for pain management?.
A. Ketorolac 60 mg q6 hours
B. Acetaminophen 650 mg q2-3hours
C. Meperidine 50mg q2hours
D. Codeine 30mg q6 hours
E. Hydromorphone 0.2mg-0.4mg q6-10minutes in a patient
controlled analgesia form
A
- Answer: E
Explanation:
Sickle cell disease represents an alteration in both beta
subunits of hemoglobin from glutamate to valine. It affl ict
about 1 in 500 African American, or 0.15%. Under certain
circumstances the red blood cells sickle in shape and cause
thrombosis in the microcirculation and tissue hypoxia.
Clinically this manifests as a painful vasooclusive crisis in
the chest, abdomen, limbs, bones, penis, kidneys, etc… In
the joints patients may develop a painful, swollen joint.
Predisposing factors include dehydration, hypothermia,
exertion, acidosis, hypoxemia, and, infection. Cocaine is
associated with an increased basal metabolic rate. In this
patient, this may have precipitated a sickle cell crisis.
The question illustrates the ethics of prescribing opioids
to a patient with a severe medical condition and a drug
history. Ketorolac and NSAIDS have a ceiling effect and
have only a modest effect in sickle cell crises. The patient
may be dehydrated given his drug use and may have
underlying renal dysfunction-both of which may preclude
NSAIDs. Acetaminophen at this dose would exceed the
4000 mg limit for short term users and the 3100 mg limit
for chronic users. Its modest analgesic effects would not
benefi t such a painful crisis. Meperidine is a weak opioid
analgesic and at the dose required, may cause a buildup of
normoperidine. This metabolite may cause a seizure.
Codeine is relatively weak as an analgesic. The PCA would
be most appropriate. Hydromorphone may be better than
morphine in some circumstances due to its longer effect,
less emetogenic, and greater potency Other therapies
include oxygen, intravenous fl uids, warm temperatures,
and hydroxyurea..
Source: Shah RV, Board Review 2006
16
Q
- A 32-year-old woman who had epidural analgesia
(bupivacaine and morphine) for vaginal delivery of a 9-
lb, 6-oz baby boy complains of numbness and footdrop
24h after delivery. The most likely cause is
A. transient neurologic defi cit due to compression of the
nerves by the baby during delivery
B. permanent neuropathy from pelvic neural compression
C. herniated intervertebral disk
D. ischemia of the conus medullaris
E. myelopathy due to epidural analgesia
A
- Answer: A
Explanation:
(Bonica)
Maternal obstetric neuropathy after vaginal
delivery is reported to occur in 1 in 2500 deliveries. The
obturator, sciatic, or pudendal plexus can be injured by
continuous pressure of the presenting part during labor or
by forceps. The defi cit is usually unilateral, but may be
bilateral. One to two days after delivery, the patient may complain of burning, aching pain in the distribution of
the injured nerve. There may be some motor impairment.
The neuropathy is usually transient, and complete
recovery often occurs after several weeks.
Source: Kahn and Desio
17
Q
- All of the following are accurate statements with
managing opioid-dependent pregnant patients
experiencing withdrawal symptoms when the drug is
discontinued, EXCEPT:
A. Methadone frequently is used to treat acute withdrawal
from opioids
B. Current federal regulations restrict the use of methadone
for the treatment of opioid addiction to specially registered
clinics
C. Methadone may be used by a physician in a private practice
for temporary maintenance or detoxifi cation when
an addicted patient is admitted to the hospital for an
illness other than opioid addiction
D. Methadone may never be used by a private practitioner
in an outpatient setting when administered daily.
E. Methadone may be used by a private practitioner in an
outpatient setting when administered daily for a maximum
of three days
A
- Answer: D
Explanation:
1.Methadone frequently is used to treat acute withdrawal
from opioids.
2.Current federal regulations restrict the use of methadone
for the treatment of opioid addiction to specially
registered clinics.
3.Methadone may be used by a physician in private
practice for temporary maintenance or detoxifi cation
when an addicted patient is admitted to the hospital for an
illness other than opioid addiction. This includes
evaluation for preterm labor, which can be induced by
acute withdrawal.
4.Methadone may also be used by a private practitioner in
an outpatient setting when administered daily for a
maximum of 3 days while a patient awaits admission to a
licensed methadone treatment program.
18
Q
- Elevated estrogen levels during the menstrual cycle
A. Decreased LH levels
B. Downregulate FSH receptors on granulosa cells
C. Increase FSH cells
D. Increase the ciliation of the epithelial cells of the oviduct
E. Decrease synthesis and storage of glycogen in the vaginal
epithelium
A
- Answer: D
Explanation:
(Junqueira, 9/e, pp 425-430. McKenzie and Klein, pp 344- - Guyton, l0/e, pp 930-933.)
Estrogen levels increase during the maturation of ovarian
follicles, which results in a concomitant increase in
ciliation and height of the oviductal lining cells. Increases
in the number of cilia serve to facilitate movement of the
ovum. Increased estrogen levels also decrease FSH levels
and cause an LH surge. Elevated estrogen levels result in
increased secretion of lytic enzymes, prostaglandins,
plasminogen activator, and collagenase to facilitate the
rupture of the ovarian wall and the release of the ovum
and the attached corona radiata. Following ovulation,
during the luteal phase of the cycle, the theca and
granulosa cells are transformed into the corpus luteum
under the infl uence of LH. Ovulation occurs near the
middle of the menstrual cycle and is associated with an
increase in basal body temperature that appears to be
indirectly regulated by elevated estrogen levels, with IL-I
functioning as the endogenous pyrogen. Estrogen also
upregulates FSH receptors on granulosa cell membranes
and enhances synthesis and storage of glycogen in the
vaginal epithelium.
Source: Klein RM and McKenzie JC 2002.
19
Q
1618. The fetal hydantoin syndrome is characterized by all except: A. Microcephaly B. Mental defi ciency C. Short stature D. Craniofacial deformities E. Variable dimorphic features
A
- Answer: C
Explanation:
The hydanantion syndrome (phenytoin) is associated with
microcephaly, mental defi ciency, craniofacial deformities, and variable dysmorhic features, but not short stature.
Source: Boswell MV, Board Review 2005
20
Q
1619. Which of the following drugs is most compatible with breast feeding? A. Amitritypline, FDA category D B. Imipramine, FDA category D C. Ergotamine, FDA category X D. Diazepam, FDA category D E. Valproic acid, FDA category D
A
- Answer: E
Explanation:
(Rathmell, JP. Mgmt of Non-obstetric Pain during
Pregnancy and Lactation. Anesth and Analg 1997; 85:
1074-87)
The FDA categories are concerned with risk of fetal harm.
The American Academy of Pediatrics has categorized
medications in relation to their safety to the infant
following ingestion by the mother.
Refer to this article:
http://aappolicy.aappublications.org/cgi/content/full/pedia
trics;108/3/776/T5
Source: Shah RV
21
Q
- A full-term male infant displays projectile vomiting 1
h after suckling. There is failure to gain weight during
the fi rst two weeks. The vomitus is not bile-stained
and no respiratory diffi culty is evident. Examination
reveals an abdomen neither tense nor bloated. The
most probable explanation is
A. Congenital hypertrophic pyloric stenosis
B. Duodenal atresia
C. Patent ileal diverticulum
D. Imperforate anus
E. Tracheoesophageal fi stula
A
- Answer: A
Explanation:
(Moore, Developing Human, 6/e, p 276.)
Blockage of the foregut in the newborn produces projectile
vomiting. Congenital hypertrophic pyloric stenosis,
occurring in 0.5 to 1.0% of males and rarely in females,
involves hypertrophy of the circular layer of muscle at the
pylorus. This usually does not regress and must be treated
surgically. During the fi fth and sixth weeks of
development, the lumen of the duodenum is occluded by
muscle proliferation but normally recanalizes during the
eighth week. Failure of recanalization results in duodenal
atresia. Because this occurs distal to the hepatopancreatic
ampulla, the vomitus will occasionally be stained with bile.
Annular pancreas, rare in itself, seldom completely blocks
the duodenum. Imperforate anus results in intestinal
distention with bloating.
Source: Klein RM and McKenzie JC 2002.
22
Q
- A 43-year-old woman as brought to a hospital emergency
room by her brother. Visiting the halfway house in
which she lived, he had found her to be lethargic,
with slurred speech. The patient had a long history
of treatment for psychiatric problems, and the brother
feared that she might have overdosed on one or more
of the several drugs that had been prescribed for
her. Physical examination revealed tachycardia with
irregular heart rate, shallow respirations, decreased
bowel sounds, dilated pupils, and hyperthermia. An
ECG revealed a widened QRS complex with diffuse T
wave changes. If this patient had taken a drug overdose
the most likely causative agent was
A. Clozapine
B. Fluoxetine
C. Lithium
D. Thioridazine
E. Zolpidem
A
- Answer: D
