Fitzgerald

Question 1

In counseling women about the use of a SSRI during pregnancy, the NP considers that studies to date reveal:

Answer 1

As more and more data become available about the effects of SSRI use during pregnancy, it has become apparent that there is a small but persistent increased risk of pulmonary hypertension in the exposed neonates. There is no link to neural tube defects, macrosomia, of gestational diabetes.

Question 2

In the pregnant woman with asthma, in what part of her pregnancy are symptoms and bronchospasm likely to worsen?

Answer 2

29-36 weeks EGA

Bronchospasm can be triggered as a consequence of increased external pressure on the smooth muscle of the bronchial structures. The increasing size of the fetus during weeks 29–36 creates significant displacement of abdominal and thoracic structures and places external pressures on the bronchi. In the last four weeks, as the fetus “drops” into the pelvis, pressure on the bronchi is actually relieved a bit and symptoms often improve.

Question 3

Medications most commonly pass through the placenta via:

Answer 3

Passive diffusion

The placenta is freely permeable and most medications that are administered to the mother just pass through the placenta along their concentration gradient until a steady state is achieved (i.e., passive diffusion). Facilitated transport and mechanical carrier state are mechanisms by which a medication requires another compound to allow the drug to pass through the membrane barrier. Pump actions are required when a medication or other compound is being actively pumped across a membrane against its concentration gradient.

Question 4

When treating a woman with a UTI who is 22-weeks pregnant, the NP prescribes:

Answer 4

Nitrofurantoin (Macrobid)

In both the pregnant and non-pregnant woman, E. coli is the most common cause of uncomplicated UTI. Nitrofurantoin is a recommended first-line agent during pregnancy (pregnancy category B).

Question 5

In treating a pregnant woman with acute bacterial rhinosinusitis, the NP would prescribe ______ and likely avoid prescribing_______

Answer 5

RX: amoxicillin, azithromycin
AVOID: Levofloxacin

Levofloxacin is pregnancy category C and would not be used when safer, effective alternatives are available. Amoxicillin and azithromycin are both indicated for acute bacterial rhinosinusitis (ABRS) and are pregnancy category B.

Question 6

The recommended duration of antimicrobial therapy for treatment of a urinary tract infection in a pregnant woman is:

Answer 6

7 days

UTIs are common during pregnancy and the most common causative pathogen is Escherichia coli. In pregnancy, hormonal changes and dilation of the renal pelvis actually favor ascension into the upper urinary tract and, therefore, UTI is treated aggressively. Because of the dangers of maternal and fetal complications from a UTI during pregnancy, a 7-day regimen of antimicrobial therapy is recommended to ensure eradication of the bacteria.

Question 7

The most likely causative organism in uncomplicated UTI during pregnancy is:

Answer 7

escheria coli (E. coli)

In both the pregnant and non-pregnant woman, E. coli is the most common cause of uncomplicated UTI. The organism is a common intestinal inhabitant and the close proximity of the anus and urethra puts women at risk for ascension of the organism into the lower urinary tract. In pregnancy, hormonal changes and dilation of the renal pelvis actually favor ascension into the upper urinary tract and, therefore, UTI is treated aggressively.

Question 8

When a pregnant woman takes a teratogenic drug, the fetal effects are usually seen in what pattern:

Answer 8

Certain target organs in a predictable manner

Most teratogenic drugs target particular organ systems, and so the embryo or fetus is most vulnerable at very specific times during development. Injury is not systemic, but rather organ-system specific and predictable.

Question 9

The release of which chemical mediator causes primary dysmenorrhea?

Answer 9

prostaglandins

Dysmenorrhea (painful menstruation) is classified as primary (from the onset of menstruation) or secondary (due to some physical cause and usually of later onset). Primary dysmenorrhea is due to the production of prostaglandins made by cells in the inner lining of the uterus. Prostaglandins cause the uterine muscles to contract and help the uterus shed the lining that has formed during the menstrual cycle. If excessive prostaglandins are produced, the woman can experience excessive pain with her menstrual cycle.

Question 10

General pathogenic mechanisms of polycystic ovarian syndrome

Answer 10

PCOS is a result of a combination of conditions that include oligoovulation or anovulation, elevated levels of androgens, or clinical signs of hyperandrogenism and polycystic ovaries.

Polycystic ovarian syndrome (POS or PCOS) is associated with abnormalities in the metabolism of androgens and estrogen and in the control of androgen production. Patients typically have high serum concentrations of androgens, including testosterone, androstenedione, and dehydroepiandrosterone sulfate (DHEAS). POS is also associated with peripheral insulin resistance and hyperinsulinemia. In POS, oligoovulation or anovulation can occur, leading to the production of cysts in the ovaries that can contribute to infertility.

Question 11

Considering the mediating factors of premenstrual syndrome (PMS), which medication can be used either continually or only during the menstrual period luteal phase of the menstrual cycle as a treatment for the condition?

Answer 11

Select SSRIs

Evidence implicates the serotonergic system is involved in the pathogenesis of premenstrual syndrome and its most intense form, premenstrual dysphoric disorder (PMDD). As a result, SSRIs are considered the most effective pharmacologic class for the treatment of PMS symptoms, such as irritability and depressed mood. SSRIs can be taken continuously or in the luteal phase of the menstrual cycle (the two weeks leading up to menstruation).

Question 12

When a woman’s uterus is assessed as protruding into the vagina to the hymen, which stage of prolapse does this indicate?

Answer 12

Stage 2

Uterine prolapse is the downward displacement of the uterus into the vaginal canal taking the vaginal wall with it. 1st degree = cervix drops into lower part of the vagina; 2nd degree = the body of the uterus lies in the vagina; cervix is at the vaginal opening; and 3rd degree = the uterus and cervix protrude through the vaginal introitus.

Question 13

Which term is used to identify the descent of the posterior bladder and trigone into the vaginal canal?

Answer 13

cystocele

Prolapses can occur in the anterior, middle, or posterior compartment of the pelvis. A cystocele comprises of a prolapse of the bladder into the vagina. An enterocele is a herniation of the pouch of Douglas (including small intestine/omentum) into the vagina. A rectocele is a prolapsed of the rectum into the vagina. A vaginocele (or colpocele) occurs when the base of the vagina drops from its normal position in women who have previously undergone a hysterectomy.

Question 14

What type of cyst develops when an ovarian follicle is stimulated but no dominant follicle develops and completes the maturity process?

Answer 14

benign ovarian cyst

Many women will develop at least one ovarian cyst during their life with most cases being asymptomatic and resolving on their own. A benign ovarian cyst develops when a follicle is stimulated but no dominant follicle develops and completes the maturation process

Question 15

What is a follicular cyst?

Answer 15

A follicular cyst occurs when the sac surrounding the egg fails to break open to release the egg, with the resulting fluid forming a cyst.

Question 16

What is a corpus albicans cyst

Answer 16

A corpus albicans cyst is typically a small hyalinized fibrous scar, sometimes with fluid, that develops after the corpus luteum involutes.

Question 17

What is a corpus luteum cyst

Answer 17

Corpus luteum cysts occur when the follicle sac fails to dissolve after releasing the egg, thus sealing the opening and allowing accumulation of fluid to form the cyst.

Question 18

Which description is used when a progressive neoplastic change involves the full epithelial thickness of the cervix?

Answer 18

Cervical carcinoma in situ (Stage 0)

Cervical dysplasia refers to abnormal changes in the cells on the surface of the cervix. Cervical dysplasia that is seen on a Pap smear is called a squamous intraepithelial lesion (SIL). If an SIL is detected, a biopsy is often needed for confirmation. A dysplasia seen on biopsy of the cervix is called cervical intraepithelial neoplasia (CIN), and these are grouped into 3 categories (I, II, III) based on severity. A progressive neoplastic change that involves the full epithelial thickness of the cervix describes cervical carcinoma in situ (CIS), or stage 0 cervical cancer. At this stage, the cancer is noninvasive and confined to the surface of the cervix.

Question 19

Which benign breast tumor affects postmenopausal women and is characterized by the principal lactiferous ducts becoming dilated and filled with cellular debris?

Answer 19

mammary duct ectasia

Mammary duct ectasia most often affects women in their 40s and 50s and is caused by inflammation of the ducts behind the nipple, causing the ducts to become clogged with thick, sticky cellular debris. Intraductal papillomas consist of small wart-like growths that project into lactiferous ducts near the nipple and usually affect women 30–50 years of age. Phyllodes tumors are rare breast tumors most common in women in their 30s and 40s.

Question 20

When ovarian cancer is associated with a known pattern of inheritance, the majority are associated with:

Answer 20

BRCA 1

Data from the National Cancer Institute show that, though only about 1.4% of women in the general population will develop ovarian cancer over their lifetimes, 39% of those with a BRCA1 mutation will develop ovarian cancer by age 70 years. This compares with 11– 17% of women with a BRCA2 mutation. The USPSTF recommends screening women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that can be associated with an increased risk for BRCA1 or BRCA2 mutations.

Question 21

Risk for ovarian cancer with BRCA 1 vs. 2

Answer 21

BRCA 1 = 39-44%

BRCA2 = 11-17%

Question 22

Which is worse, BRCA 1 or 2?

Answer 22

BRCA 1

Question 23

Risk for breast cancer with BRCA 1 vs. 2

Answer 23

BRCA 1 = 55%–72%

BRCA 2 = 45%–69%

Question 24

Anovulatory bleeding is abnormal uterine bleeding resulting from (2)

Answer 24

• estrogen excess
• progesterone deficiency

Anovulatory bleeding results from a disruption in the normal cyclic pattern of ovulatory stimulation to the endometrial lining. The bleeding in these patients is unpredictable (heavy or light, short or prolonged, frequent or random). As a result of cyclic disruption, patients have constant, non-cycling estrogen levels along with progesterone deficiency (as this is normally released during the luteal phase) that stimulates endometrial growth.

Question 25

The size of benign uterine tumors, such as leiomyomas, is thought to be caused by the influence of which hormone(s)? (Select all that apply.)

Answer 25

• estrogen
• progesterone
• growth factors

Benign uterine tumors, or fibroid tumors, are non-cancerous and comprised of fibrous tissue. Tumors can range in size and number, and can range from 1 mm to more than 20 cm in diameter. The cause of these tumors is not completely understood, but most develop in women during their reproductive years, but not before the production of estrogen. Hence, estrogen as well as progesterone and other growth factors can influence tumor size. Any association of luteinizing hormone (LH) or gonadotropin-stimulating hormone (GnRH) on tumor size has not been demonstrated.

Question 26

What are the two most common clinical manifestations of endometriosis?

Answer 26

• infertility
• dysmenorrhea

Endometriosis occurs when endometrial cells grow outside the uterus, most commonly involving the ovaries, bowel, and tissue lining the pelvis. Most women with endometriosis have no symptoms. However, those with symptoms can experience dysmenorrhea, pain with intercourse, pain with bowel movements or urination, and excessive bleeding. Infertility is a common consequence of the condition. Other symptoms can include fatigue, diarrhea, constipation, and bloating and nausea, especially during menstrual periods.

Question 27

When caring for a patient with alpha thalassemia minor, the nurse practitioner knows that primary care should include:

Answer 27

offering genetic counseling prior to pregnancy

Alpha thalassemia minor is an inherited genetic abnormality in one or both of the alpha chains of the hemoglobin protein. Two parents with alpha thalassemia minor can produce an offspring with the most serious form of the disease and genetic counseling is imperative. Since alpha thalassemia minor is not a product of micronutrient deficiency, supplementation is not indicated and in some cases (as with iron) can be dangerous. Hemoglobin electrophoresis identifies the form of hemoglobin, which does not change over time.

Question 28

What is alpha thalassemia minor and how is it diagnosed

Answer 28

inherited hemoglobinopathy, genetic abnormality in one or both of the alpha chains of the hemoglobin protein&raquo_space; leads to anemia

diagnosed with RBC electrophoresis

Question 29

alpha thalassemias occur most commonly in patients of _____ origin, whereas beta thalassemias are predominant in patients of ______ descent

Answer 29

Alpha = Asian, African
Beta = Mediterranean

Question 30

Pollen counts are highest in the _________ and allergy sufferers are advised to stay indoors and keep windows closed as much as possible during these hours in order to minimize exposure

Answer 30

early morning hours (5:00 a.m. to 10:00 a.m.)

Question 31

Classic finding at the onset of herpes zoster

Answer 31

A 1–2 day prodrome of pain prior to lesions erupting

Question 32

You see a 14-year-old girl at Tanner stage 2–3 who complains of being the shortest in her class. You advise:

Answer 32

that her growth spurt will start soon

The adolescent growth spurt does not occur until Tanner stage 3, so this patient has not reached that point in her physical development. Having reached Tanner stage 2–3 by the age of 14 reassures the nurse practitioner that the patient’s puberty is progressing appropriately. The best response is to tell her that she has not achieved her growth spurt yet, but that it will likely begin soon. Referral to an endocrinologist or for a bone age evaluation is not appropriate for this patient as her developmental pattern is consistent with normal expectations.

Question 33

Adolescent growth spurt does not occur until Tanner Stage….

Answer 33

Stage 3

Question 34

Tanner Stage 1

Answer 34

~age 8yo
pre-adolescent, no noticeable changes

early pulsatile signals beginning from HPO-axis

Question 35

Tanner Stage 2

Answer 35

~ages 9-11yo

Breast “buds” start to form; pubic hair starts to form

Question 36

Tanner Stage 3

Answer 36

~age 12yo
Acne first appears; armpit hair forms; height increases at its fastest rate (peak height velocity), changes in fat distribution

Question 37

Tanner Stage 4

Answer 37

~age 13yo

First period arrives

breasts continue to fill out, pubic hair more coarse

Question 38

Tanner Stage 5

Answer 38

~age 15yo

final stage
breasts reach adult size and shape (though may continue to change through age 18yo)
periods become more regular
may be at adult height 1-2 years after first period

Question 39

In a woman taking a combined oral contraceptive, the reduction in free androgens can yield an improvement in:

Answer 39

acne vulgaris

Free androgens, a precursor of testosterone, are linked to acne vulgaris. Combined oral contraceptives decrease free androgens, and consequently can improve acne vulgaris. While hormonal contraception can improve cycle control, it is not due to the androgen suppression but due to the consistent estrogen and progesterone administration. Similarly, breast tenderness is linked to estrogen fluctuations.

Question 40

A 22-year-old woman presents for hepatitis screening. She is without symptoms but needs the testing for a job in the food service industry. Laboratory results are as follows: Anti-HCV with HCV RNA =positive. HBsAg=positive. Anti-HAV=negative. You advise the patient that she has….

Answer 40

chronic hepatitis B and C

is not immune to hepatitis A and recommend vaccination

This patient is seropositive for anti-HCV with HCV RNA present and, therefore, has an active hepatitis C infection. She is also positive for the hepatitis B surface antigen (HBsAg positive) and, therefore, has hepatitis B. However, she is seronegative for the antibody to the hepatitis A virus (anti-HAV negative) and, therefore, is susceptible to hepatitis A. It is appropriate to offer this patient vaccination against hepatitis A.

Question 41

A 27-year-old woman presents for care. She reports a 3-day history of intense vaginal itch, burning with urination, and white, clumping discharge. She denies a foul odor but says it does smell a little musty. What history finding supports your diagnosis?

Answer 41

recent antibiotic use

The symptoms described are classic signs of a vaginal candidiasis (i.e., yeast infection), a fungal infection characterized by “spaghetti and meatball” pseudohyphae on microscopic examination. Antimicrobial use is a risk factor for yeast infections as the antimicrobial disrupts the normal bacterial flora of the genitourinary tract, thus allowing overgrowth by colonizing organism (e.g., Candida albicans). Vaginal candidiasis can develop during or following systemic antimicrobial therapy.

Question 42

A 29-year-old well woman of Mediterranean ancestry presents for her first healthcare visit in many years. She relocated to North America from Italy after marrying a member of the US Armed Forces. A routine CBC reveals the following results:

–Hgb=9.6 g/dL (12–14 g/dL) (96 g/L [120–140 g/L])
–Hct=30% (36–42%) (.30 proportion [.36–.42 proportion])
–MCV=66 fL (80–96 fL)
–RDW=12% (<15%) (.12 proportion) (

Answer 42

beta thalassemia minor

• LOW Hgb
• LOW Hct
• LOW Mcv
• normal RDW
• normal RBCs

** very closely resembles iron-deficiency anemia, but you would expect elevated RDW in IDA

The mean cell volume (MCV) of 66 fL indicates microcytic anemia (normal MCV=80–96 fL). Iron deficiency anemia and thalassemia are the two most common microcytic anemias encountered in primary care and represent the leading differential diagnoses. Iron deficiency is most commonly a consequence of slow, steady blood loss and resulting depletion of iron, whereas thalassemia is a genetic disorder and not related to iron or any micronutrient deficiency. The normal red blood cell distribution width (RDW) indicates a stable anemia of long duration. Mediterranean ancestry is a risk factor for thalassemia, and the fact that the patient is a 29-year-old well woman suggests that this is a thalassemia minor form, with no impact on health. Consideration should be given to providing genetic counseling prior to pregnancy.

Question 43

A 36-year-old woman presents with a 12-h history of anorexia, nausea, and right lower quadrant abdominal pain. A white blood cell count with differential demonstrates:
 –Total WBC=16,500 cells/mm³ 
–Neutrophils=66% 
–Bands=8%
 –Lymphocytes=22%

You suspect…..

Answer 43

appendicitis

This constellation of clinical symptoms is highly suggestive of appendicitis. The obturator and psoas signs are both consistent with pain during peritoneal stretch in the region of the appendix and are closely associated with appendicitis; the coincident abdominal pain, anorexia, and nausea strengthen the diagnosis. Consequently, the white blood cell (WBC) count will likely demonstrate an increase characterized by elevated neutrophils and bands; this pattern is commonly referred to as the “left shift”.

Question 44

A 37-year-old woman presents with a 2-day history of right flank pain, fever, and vomiting. Physical examination is significant for costovertebral angle tenderness. A urinalysis is likely to reveal:

Answer 44

WBC casts

The symptoms presented by this woman suggest pyelonephritis, which is a serious bacterial infection of the renal parenchyma. The large number of white blood cells (WBCs) that migrate to the site of infection result in the accumulation of WBC casts in formed urine. Among the choices, the presence of WBC casts is the most specific indicator of an infectious condition.

Question 45

A 41-year-old woman was recently diagnosed with systemic lupus erythematous. She complains of feeling generally fatigued and sometimes experiences palpitations. Her hemogram results are as follows:
 –Hgb=9.7 g/dL (97 g/L) 
–Hct=28% (0.28 proportion) 
–MCV=86 fL 
–RDW=12.5% (0.125 proportion) 
–Reticulocytes=0.9% (0.009 proportion)

These findings are most consistent with:

Answer 45

anemia of chronic disease

• Hgb LOW
• Hct LOW
• normal MCV
• normal RDW
• reticulocytes ???

(recticulocytes are low per the answer from Fitzgerald, normal per UpToDate)

The normal mean cell volume (MCV) indicates that both hemoglobin synthesis and red blood cell formation are unimpaired. The leading differentials for normocytic (MCV=80– 96 fL) anemia are anemia of chronic disease (ACD) and acute blood loss. The decreased reticulocyte count is a mechanism of ACD that in part results from increased differentiation of stem cells to white blood cells, with a resultant decrease in red blood cell production.

Question 46

A 45-year-old woman complains of bilateral, intermittent itchy eyes, often accompanied by a rope-like discharge. The nurse practitioner expects that the history will include a patient report of:

Answer 46

seasonal allergies

Allergic conjunctivitis is characterized by itchiness, as most allergic reactions are. Unlike other forms of conjunctivitis, allergic conjunctivitis typically presents as bilateral. The rope-like discharge also supports a diagnosis of allergic conjunctivitis, in contrast to the watery discharge of viral conjunctivitis and purulent discharge of bacterial conjunctivitis. Corneal injury will be described as painful, not itchy. Sexually transmitted infection, such as gonorrhea or chlamydia, will likewise not itch, but will produce an irritation characterized by more infectious symptoms. Finally, decreased visual acuity suggests a more serious problem like uveal inflammation, intraocular pressure elevations, or retinal disease.

Question 47

A 47-year-old woman presents for evaluation of erythematous, papular lesions on her forehead and chin. What is the most likely diagnosis?

Answer 47

acne rosacea

Acne vulgaris and acne rosacea are characterized by similar morphologies and distributions and both frequently are found on the forehead and chin. Tinea facialis does occur on the face but is characterized by the discrete annular lesions of tinea infection. Atopic dermatitis (eczema) is more common in children, though it can persist into adulthood, and is characterized by red- to brownish-grey patches most commonly on the hands, feet, ankles, wrists, neck, upper chest, and inside the bend of elbows and knees. In infants, the face and scalp can be affected.

Question 48

A 52-year-old woman presents to your office as a new patient. She reports a long history of high blood pressure and admits that she does not regularly take her medication. What would be anticipated funduscopic findings?

Answer 48

• arteriolar narrowing
• AV nicking
• arteriosclerosis with moderate vascular wall changes (copper wiring)
• more severe vascular wall hyperplasia with thickening (silver wiring)

A long history of chronic poorly controlled hypertension can result in various ophthalmic changes, including permanent arterial narrowing, arteriovenous nicking, and arteriosclerosis with moderate vascular wall changes (copper wiring) to more severe vascular wall hyperplasia with thickening (silver wiring).

Question 49

An increased cup:disc ratio is a sign of _____ caused by ________

Answer 49

sign of glaucoma

caused by elevated intraocular pressure

Question 50

Major risks factors for macular degeneration include….

Answer 50

• age
• family history
• cigarette smoking

Macular degeneration is typically age-related and the leading cause of vision loss in those 55 years and older. A family history of the disease and cigarette smoking are implicated as risk factors for macular degeneration.

Question 51

Leading cause of vision loss in those 55yo and older

Answer 51

macular degeneration

Question 52

A 54-year-old woman presents for evaluation of a “cold sore” on her tongue. She has never had one in the past. She denies any pain, drainage, foul taste, or any other symptoms—“just have this sore that has been there for a while.” The history is significant for a 62 pack-year smoking history, currently smoking 1 PPD. Physical examination reveals an ulcerated lesion with firm, palpable, indurated margins. The most likely diagnosis is:

Answer 52

squamous cell carcinoma

Given this patient’s long history of cigarette smoking and the lesion’s characteristics, squamous cell carcinoma (SCC) should be suspected. More than 95% of patients with oral SSC smoke tobacco, drink alcohol, or both; this disease is often associated with human papilloma virus 16 infection. These lesions are typically asymptomatic initially and are often indurated and firm with a rolled border. Pain, dysarthria, and dysphagia can result as the lesions increase in size.

Question 53

What is aphthous stomatitis

Answer 53

Aphthous stomatitis consists of shallow, painful ulcers that typically last 7–10 days.

A condition of benign, noncontagious, painful ulcers of the oral mucosa. Typically occur sporadically but can be triggered by viral infections and local trauma. Recurrent aphthous ulcers may be a sign of an underlying condition (e.g., Behçet disease, Crohn disease, celiac disease, vitamin B12 deficiency).

Question 54

Most important risk factors for oral squamous cell carcinoma (3)

Answer 54

• smoking tobacco
• alcohol
• HPV 16

Question 55

A physiologic (or “innocent”) murmur, which is by definition not associated with cardiac pathology, is characterized by several features, but one of the most definitive is that it typically …..

Answer 55

typically becomes softer when the patient stands.

The increased intracardiac volume that occurs when in the supine position exaggerates the murmur. When the patient stands, there is less volume in the heart chambers and the murmur decreases in intensity. This is directly opposite to the pathologic murmur of hypertrophic cardiomyopathy, in which the murmur becomes louder when the patient stands as a consequence of less fluid displacing the hypertrophic cardiac walls.

Question 56

What is Grave’s Disease

Answer 56

Graves’ disease is an autoimmune disorder characterized by the pathologic production of thyroid stimulating immunoglobulins (TSI) that stimulate the thyroid gland and lead to elevated thyroxine levels. The elevated thyroxine levels suppress pituitary production of thyroid stimulating hormone (TSH). As a result, TSH levels will become very low, often undetectable. According to the American Thyroid Association (ATA), the TSH level is the most sensitive indicator of thyroid function.

Question 57

According to the American Thyroid Association (ATA), the _____ level is the most sensitive indicator of thyroid function.

Answer 57

TSH

Question 58

Migraines with aura represent what category on the Medical Eligibility Criteria for COCs

Answer 58

Category 4 (contraindicated)

The Centers for Disease Control and Prevention (CDC) created the U.S. Medical Eligibility Criteria for Contraceptive Use to offer recommendations for the use of specific contraceptive methods by women who have certain characteristics or medical conditions. Migraine with aura is a Category 4 circumstance (use represents unacceptable risk). Adequately-controlled hypertension is a Category 3 condition (risk usually outweighs the advantages), while smoking is a Category 2 circumstance for those <35 years of age, and a Category 3 circumstance for those =35 years (for those who smoke <15 cigarettes per day).

Question 59

Adequately-controlled HTN represents what category on the Medical Eligibility Criteria for COCs

Answer 59

Category 3 (risks usually outweigh the advantages)

Question 60

Tobacco use represents what category on the Medical Eligibility Criteria for COCs

Answer 60

Category 2 for those <35yo (benefits usually outweigh the risks)
Category 3 for those 35yo+ (risks usually outweigh the advantages)

Question 61

BMI 30 or greater represents what category on the Medical Eligibility Criteria for COCs

Answer 61

Category 2 (benefits usually outweigh the risks)

The Centers for Disease Control and Prevention (CDC) created the U.S. Medical Eligibility Criteria for Contraceptive Use to offer recommendations for the use of specific contraceptive methods by women who have certain characteristics or medical conditions. Obesity (BMI ≥30 kg/m²) is a Category 2 circumstance (advantages outweigh risks). The presence of varicose veins is a Category 1 condition (no restriction on contraceptive use). A personal history of Factor V Leiden mutation is a Category 4 circumstance (use represents unacceptable health risk).

Question 62

Presence of varicose veins represents what category on the Medical Eligibility Criteria for COCs

Answer 62

Category 1 (no restriction)

Question 63

Personal history of Factor V Leiden mutation represents what category on the Medical Eligibility Criteria for COCs

Answer 63

Category 4 (contraindication)

Question 64

Actinic keratoses can be described as:

Answer 64

Actinic keratosis is most often described as a rough or sandpaper-textured pink, tan, or flesh-colored lesion on a sun-exposed region of the body

Question 65

Actinic keratosis can be a precursor to:

Answer 65

squamous cell carcinoma

Actinic keratosis (AK) is considered a precancerous lesion given the possibility that it can progress to squamous cell carcinoma (SCC). AK does not progress to basal cell carcinoma or malignant melanoma. Approximately 1 AK lesion in 100 progress to SCC.

Question 66

Activities are those that truly prevent disease, illness, or health deviation are referred to as _____ prevention

Answer 66

primary prevention

Question 67

Strategies that identify asymptomatic disease before damage occurs is referred to as _____ prevention

Answer 67

secondary prevention

Question 68

Strategies that prevent further deterioration from an existing condition are referred to as _______ prevention

Answer 68

tertiary prevention

Question 69

Patients with this common chronic condition are at higher risk for vulvovaginal candidiasis infections

Answer 69

diabetes

Question 70

Hepatic adenoma represents what category on the Medical Eligibility Criteria for COCs

Answer 70

Category 4 (contraindicated)

The Centers for Disease Control and Prevention (CDC) created the U.S. Medical Eligibility Criteria for Contraceptive Use to offer recommendations for the use of specific contraceptive methods by women who have certain characteristics or medical conditions. The presence of hepatic adenoma is a Category 4 circumstance (use represents unacceptable risk). Age <40 years is Category 1 (no restriction on use) while age ≥40 years is Category 2 (advantages outweigh risks of use). Smoking by women <35 years old is a Category 2 circumstance.

Question 71

Age <40yo represents what category on the Medical Eligibility Criteria for COCs

Answer 71

Category 1 (no restriction)

Question 72

Age 40yo or older represents what category on the Medical Eligibility Criteria for COCs

Answer 72

Category 2 (benefits usually outweigh the risks)

Question 73

(3) factors implicated in acne vulgaris exacerbation

Answer 73

Sebaceous oil production, high levels of androgens, and frequent touching of the face have all been implicated in acne vulgaris exacerbation.

Question 74

In advising a woman with menstruation-related migraine and combined oral contraceptive use, the nurse practitioner considers that:

Answer 74

uninterrupted use (continuous cycling) can minimize headache frequency and severity

In women with menstruation-related migraines on hormonal contraception, it is the fluctuation in hormone levels that is most closely linked to etiology of migraine. Uninterrupted use, and subsequently hormone levels, can help minimize headache frequency and severity. Estrogen can exacerbate headache, and high doses should be avoided.

Question 75

Laboratory assessment of a patient with Hashimoto’s thyroiditis typically includes the presence of:

Answer 75

antithyroid peroxidase antibodies (anti-TPO antibodies)

Hashimoto’s thyroiditis is a condition characterized by the pathologic production of antithyroid peroxidase (anti-TPO) antibodies that block thyroid stimulating hormone (TSH) receptors on the thyroid gland. The gland does not function normally, and the result is hyperfunction of the pituitary and an elevated TSH.

Question 76

Is it okay to continue breastfeeding when diagnosed with mastitis, or should the patient stop breast feeding or pump and dump?

Answer 76

ok to keep breastfeeding!

An engorged breast can actually contribute to mastitis, so the breast should be emptied completely. It is safe for the baby to nurse when the mother has mastitis, and so normal breastfeeding patterns should not be interrupted. If the mother is uncomfortable, she can be encouraged to begin with the unaffected breast and then switch to the affected breast.

Question 77

Prophylactic treatment options for migraine include (3)

Answer 77

propanolol, timolol, topiramate

A variety of prophylactic therapies are used in patients with migraine headache with varying degrees of success, but topiramate and noncardioselective beta-adrenergic antagonists (e.g., propranolol) are generally regarded as among the most effective. Verapamil is no longer considered an effective option for migraine control. Ergotamine and sumatriptan are used for the management of acute migraine, but not for prevention. When prescribing topiramate, its teratogenic potential should be kept in mind.

Question 78

(3) most common causative agents for bacterial infections of the HEENT

Answer 78

1. streptococcus pneumoniae
2. haemophilus influenzae
3. M. catarrhalis

The most common organism implicated in bacterial infection of the head and neck, including acute bacterial rhinosinusitis (ABRS), acute otitis media (AOM), and bacterial pharyngitis, is S. pneumoniae. The second most common organism is H. influenzae while M. catarrhalis is a distant third.

Question 79

Most common causative agents for acute otitis media (3)

Answer 79

1. strep pneumonia
2. h. influenzae
3. m. catarrhalis

Question 80

Most common causative agents for acute bacterial rhinosinusitis

Answer 80

1. strep pneumonia
2. h. influenzae
3. m. catarrhalis

Question 81

What is strep throat most commonly caused by

Answer 81

group a beta-hemolytic streptococcus (group A strep)

Question 82

What is community acquired pneumonia most commonly caused by

Answer 82

strep pneumonia

Question 83

type 1 diabetes mellitus is almost always a result of …

Answer 83

autoimmune-mediated pancreatic dysfunction

Question 84

_____ headaches are typically described as bilateral and pressing in quality (i.e., non-pulsating), characterized by the relative absence of associated symptoms and photophobia and phonophobia are seldom reported, symptoms are improved with distraction activities.

Answer 84

tension

Question 85

Most common benign neoplasm of the cervix in folks between 30-50yo is….

Answer 85

cervical polyp

Cervical polyps occur in about 2–5% of women and most often affect women over the age of 20 years who have had children. They can cause irregular menstrual bleeding but often are asymptomatic. The Bartholin’s glands are not located on the cervix but on each side of the vaginal opening and secrete fluid that helps to lubricate the vagina. The openings of these glands can become obstructed, leading to the formation of a cyst. Cervical myomas are less common and usually coexist with uterine myomas (fibroids).

Question 86

Molloscum contagiosum can be treated with….

Answer 86

trichloroacetic acid (TCA) or cryotherapy (liquid nitrogen)

Molluscum contagiosum is a relatively common viral infection of the skin that results in round, firm, painless bumps ranging in size from a pinhead to a pencil eraser. If the bumps are scratched or injured, the infection can spread to the surrounding skin. Though lesions typically resolve over time without treatment, removal is recommended given the highly contagious nature of the infection. Effective treatments include blistering agents (e.g., trichloroacetic acid) or cryotherapy (e.g., liquid nitrogen). Azithromycin, erythromycin and benzoyl peroxide are not effective against viral infections.

Question 87

relatively common viral infection of the skin that results in round, firm, painless bumps ranging in size from a pinhead to a pencil eraser. If the bumps are scratched or injured, the infection can spread to the surrounding skin. Though lesions typically resolve over time without treatment, removal is recommended given the highly contagious nature of the infection

This describes….

Answer 87

molloscum contagiosum

Question 88

Greatest risk of infection with placement of an IUD occurs when?

Answer 88

within 20 days of insertion

Infection related to IUD use is usually the result of insertion where contamination of the uterine cavity with organisms from the vaginal flora occurs at the time of insertion. However, the risk of infection is minimal (~1%) and is limited to the first 20 days after insertion. Infections that occur beyond 20 days of insertion are likely to be sexually transmitted. Timing of insertion has no impact on infection risk, and antimicrobial prophylaxis has been shown to provide no benefit.

Question 89

Optimal pregnancy interval

Answer 89

> 18-24 months

less than 5 years

Question 90

Some risk factors for preterm birth

Answer 90

• prior preterm birth
• multiple gestation
• polyhydramnios
• uterine anomalies
• incompetent cervix
• infection of the genitourinary tract
• short interval between pregnancies (<18 months)
• inadequate weight gain
• poor nutrition
• uteroplacental insufficiency, smoking cigarettes, etc…..

Question 91

At what point in the pregnancy does the CDC recommend screening for group B Streptococcus (GBS)?

Answer 91

35-37 weeks

Neonatal infection with group B Streptococcus (GBS) is a leading cause of newborn morbidity and mortality. Maternal lower genitourinary tract colonization with GBS is a major risk factor for early-onset disease, usually in the first week of life. The transmission of the organism from mother to fetus usually occurs after the onset of labor or membrane rupture. As a result, GBS screening should be performed in all women at 35 to 37 weeks of pregnancy, including women who are to undergo cesarean birth because the organism can cause infection across intact membranes.

Question 92

Do you still need to screen for GBS in someone planning an elective cesarean?

Answer 92

Yes, in case they go into preterm labor AND because the organism can cause infection across intact membranes.

Question 93

What change is a result of pubertal changes and helps defend the vagina from infection?

Answer 93

During puberty, the vaginal pH becomes more acidic, ranging from 3.8– 4.2 in healthy women of reproductive age, which inhibits growth of bacteria (though Candida species are viable in pH <4.5). During this time, estrogen production increases to induce the development of secondary sex characteristics. Physiologic leukorrhea is an anticipated puberty finding.

Question 94

Normal vaginal pH, after puberty until menopause

Answer 94

3.8-4.2 (<4.5)

Question 95

A woman with a past history of carrying a pregnancy where the fetus had a neural tube defect should be advised to…..

Answer 95

take 4mg (400mcg) folic acid daily for 3 months prior to attempting next pregnancy

Folic acid deficiency is a teratogenic state, leading to an increased risk of a neural tube defect (NTD) and other defects in the developing pregnancy. Correcting folic acid deficiency before pregnancy by increased dietary and supplement intake dramatically reduces the risk of defects, and continuing this increased intake during pregnancy minimizes the mother’s risk of developing folate deficiency anemia. As a result, if a woman has carried a pregnancy with an NTD, or there is a family history of NTD, recommended folic acid intake is 4 mg per day for 3 months before attempting a subsequent pregnancy.

Question 96

Within the first hours after a normal spontaneous vaginal delivery, a woman can exhibit an elevated WBC count (>20,000 mm³) as well as slight temperature elevation. This is a typical response in the immediate postpartum woman due to….

Answer 96

dehydration

During the postpartum period, women can exhibit a slight temperature elevation due to dehydration following delivery. It is also normal for the WBC count to increase markedly during labor, rising up to 20,000 to 30,000 mm³ in the first 24 hours postpartum. The WBC count will return to normal within 1 week. As a result, the woman should be encouraged to drink adequate amounts of fluids and to rest. Additional diagnostic tests are not warranted.

Question 97

WBC count is expected to return to normal levels within _____ post-partum

Answer 97

1 week

Question 98

WBC count can physiologically increase to as high as _______ during labor and in the first 24 hrs postpartum

Answer 98

20,000-30,000 mm3

Question 99

<21 days postpartum represents what category on the Medical Eligibility Criteria for COCs

Answer 99

category 4 (contraindicated)

Initiation of contraception during the postpartum period is important to prevent unintended pregnancy and short birth intervals. However, the use of combined oral contraception (COC) during the first 21 days after delivery is not recommended due to a high risk of venous thromboembolism during this period (US MEC Category 4). Use of COC during 21 to 42 days postpartum is given Category 2/3 (depending on presence of other risk factors for VTE), while no restrictions are placed on COC use >42 days postpartum (Category 1). Progestin-only pills (POP) are generally regarded as the better choice in breastfeeding mothers as they do not interfere with the milk supply in the way that estrogen-containing contraceptives can. POPs can be used safely during breastfeeding in the immediate postpartum woman (Category 2). DMPA injection and etonogestrel implants are also safer alternatives to COC in immediate postpartum breastfeeding women (Category 2).

Question 100

> 42 days postpartum represents what category on the Medical Eligibility Criteria for COCs

Answer 100

category 1 (no restriction), although progestin-only pills are generally regarded as the better choice for folks who are breastfeeding as they are not thought to interfere with milk supply in the same way that estrogen does

Question 101

<21 days postpartum and breastfeeding represents what category on the Medical Eligibility Criteria for progestin-only pills

Answer 101

category 2 (benefits typically outweigh risks)

Question 102

<21 days postpartum and breastfeeding represents what category on the Medical Eligibility Criteria for DMPA

Answer 102

category 2 (benefits typically outweigh risks)

Question 103

<21 days postpartum and breastfeeding represents what category on the Medical Eligibility Criteria for Nexplanon (etonorgestrel implant)

Answer 103

category 2 (benefits typically outweigh risks)

Question 104

The hormone responsible for milk production is _____ from the _______

Answer 104

prolactin from the anterior pituitary

Prolactin is produced in the anterior portion of the pituitary gland and its primary role is to promote lactation. In breastfeeding women, the suckling infant triggers the release of oxytocin from the posterior pituitary, which is carried via the bloodstream to the mammary glands where it interacts with specific receptors on myoepithelial cells. This initiates their contraction and expels milk from the alveoli.

Question 105

The hormone responsible for milk ejection is _____ from the _______

Answer 105

oxytocin from the posterior pituitary

Prolactin is produced in the anterior portion of the pituitary gland and its primary role is to promote lactation. In breastfeeding women, the suckling infant triggers the release of oxytocin from the posterior pituitary, which is carried via the bloodstream to the mammary glands where it interacts with specific receptors on myoepithelial cells. This initiates their contraction and expels milk from the alveoli.

Question 106

A prenatal patient tested positive for hepatitis B surface antigen (HBsAg) and you have advised her of these test results. You have also explained that upon delivery of her infant, the following actions will be taken….

Answer 106

administration of hepatitis B vaccine and hepatitis B immune globulin (HBIG) will be administered to the neonate within 12 hours of birth

The presence of HBsAg indicates that the mother is currently infected with hepatitis B. Therefore, the neonate should be given hepatitis B immune globulin to confer immediate protection and allow the mother to breastfeed. Hepatitis B immunization should be given in accordance with typical childhood vaccination schedules to ensure that the child develops long-term active immunity.

Question 107

If mother has positive HBsAg and neonate received the hepatitis B vaccine and HBIG at birth, can they engage in breastfeeding?

Answer 107

yes

there is no need to delay breastfeeding until the infant is fully immunized. The risk of HBV mother-to-child transmission through breastfeeding is negligible if infants born to HBV-positive mothers receive the HBIG/HBV vaccine at birth.

Question 108

What is the most specific finding for DVT

Answer 108

unilateral edema

The most specific finding for DVT is edema (usually unilateral), and a bilateral calf measurement can be helpful in clinical assessment. Other signs include leg pain, warmth over the area of thrombosis, and tenderness. Homan’s sign (pain on dorsiflexion of the foot) is present in about one-third of those with DVT. Numbness in the toes and heel of the foot is not a typical sign for DVT.

Question 109

Homan’s sign for DVT

Answer 109

pain on dorsiflexion of the foot, present in 33% of those with DVT

Question 110

You see a breastfeeding client with a previous history of mastitis who presents with a painful, hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T= 103.8°F (39.9°C), HR= 110, RR= 25, and BP=110/60 mm Hg.

You suspect _____ and recommend the following to confirm the diagnosis…

Answer 110

• abscess
• CBC with diff, breast US

Breast abscess is characterized by localized breast edema, erythema, warmth and pain and can cause symptoms of fever, nausea, vomiting, and spontaneous drainage from the mass or nipple. A history of prior breast infection (e.g., mastitis) can increase the risk of an abscess. A patient suspected of an abscess should have a CBC with differential and an ultrasound to confirm the diagnosis. Management should include analgesia, antimicrobial therapy, and prompt surgical consultation to prevent complications.

Question 111

A 27-year-old woman who is 4-weeks postpartum and exclusively breastfeeding her healthy term infant presents with complaints of a 2 cm localized area of swelling, redness and tenderness to the left breast approximately 3 cm anterior of the areola. Her vital signs are within normal limits. She reports that she experienced a similar episode before that resolved spontaneously. You diagnose her with:

Answer 111

possible galactocele

A galactocele is essentially a retention cyst resulting from lactiferous duct occlusion. It is characterized by a discrete, firm, and sometimes tender breast lump that can form over weeks to months, typically located in the subareolar region. Fever or other signs of illness is usually absent.

Question 112

Which of the following should be performed first when preparing to insert an intrauterine contraception (IUC) on someone you have not previously examined?

Answer 112

bimanual exam

IUDs can be inserted anytime during the menstrual cycle after a negative pregnancy test result, if the WHNP can be “reasonably certain” the patient is not pregnant. An IUD should not be inserted in a woman with a known sexually transmitted infection (STI). STI screening may be done before or at the time of IUD insertion. Prior to insertion, a bimanual examination is performed to determine the position of the uterus. The cervix and adjacent vaginal fornices are then cleansed with an antiseptic solution. A tenaculum is used during the insertion process to stabilize the cervix. The use of antimicrobial prophylaxis is not recommended as it has been shown to provide no benefit in preventing infection.

Question 113

Though IUC/IUDs can be an effective option for birth control, there is an increased risk for serious complications if a pregnancy occurs during their use. Keeping the IUC/IUD in place during a pregnancy can increase the risk for (3)

Answer 113

• miscarriage/SAB
• placental abruption
• premature delivery

Question 114

In advising a client who wishes to become pregnant, you mention that she is most fertile when her cervical mucus is clear, watery and stretchy, which is the time when it is under the effect of:

Answer 114

estrogen

Estrogen causes a thinning of and increased production of cervical mucus, thus facilitating sperm migration to the ova. The mucus at this stage is described as clear, watery, and stretchy. Progesterone causes a thickening of the cervical mucus that inhibits sperm migration.

Question 115

Emergency contraceptives are most effective when used within….

Answer 115

3-5 days

Some emergency contraceptive methods, in particular the use of ulipristal or insertion of a CU-IUD, are effective for up to 120 hours (5 days) following intercourse. Oral levonorgestrel is most effective as an EC agent when used within 72 hours post coitus.

Question 116

Ulipristal acetate (Ella) is effective as emergency contraception when used within…..

Answer 116

5 days (120 hours)

Question 117

the copper IUD (Paraguard) is effective as emergency contraception when used within….

Answer 117

5 days (120 hours)

Question 118

Plan B (levonorgestrel) is most effective as an emergency contraception when used within…..

Answer 118

3 days (72 hours)

Question 119

Use of vaginal pH in differentiating yeast from bacterial vaginosis

Answer 119

vaginal pH of <4.5 usually indicates a Candida infection while a pH >4.5 indicates a bacterial infection.

Question 120

Amine odor (KOH “whiff” test) is present in….

Answer 120

bacterial infections/bacterial vaginosis

absent in yeast infection

Question 121

A KOH wet mount can be used to detect the presence of …..

Answer 121

pseudohyphae associated with Candida infection

Question 122

saline wet mount can be used to identify the presence of….

Answer 122

mycelia, budding yeast (Candida infection)

and clue cells (BV)

Question 123

You see an 18-year-old female who started taking combined oral contraceptives about 1 month ago. She mentions that she thought her acne would improve with COC use but she has not seen any difference. In regards to acne improvement, you counsel her that:

Answer 123

It can take up to 3 months to see any effect on acne

Acne is associated with the presence of high levels of androgens. Therefore, selecting a contraceptive option that will lower androgen levels (i.e., those containing estrogen) can lead to improvement in acne. Significant improvement in acne can take up to 3 months of COC use.

Question 124

Non-contraceptive benefits of combined oral contraceptives include (3)

Answer 124

• reduced risk for endometrial cancer
• reduced risk for ovarian cancer
• prevention of bone loss

Question 125

Combined oral contraceptives can increase the risk of (2) cancer with long-term use

Answer 125

breast cancer

cervical cancer

Question 126

You are making rounds on the postpartum unit and examine a woman who had a normal spontaneous vaginal delivery 10 hours ago. You would expect to find the fundus, vagina, and peripad in the following state

Answer 126

fundus midline, at the umbilicus
vagina gaping
peripad moderate bright red blood

Immediately following delivery, the fundus can be located between the symphysis pubis and umbilicus. Within 12 hours of delivery, the fundus rises to the level of the umbilicus, and by the second day the fundus begins to descend into the pelvis approximately 1 cm per day. Other normal findings at this time would include the vagina gaping and bright red bleeding on the perineal pad.

Question 127

Fundal height expectations at delivery and postpartum

Answer 127

• immediately after delivery = between symphysis and umbilicus
• within 12 hours of delivery = rises to the umbilicus
• by day after delivery = descends into the pelvis 1cm per day
• by 6 weeks = returns to pre-pregnant size

Question 128

The most sensitive urine pregnancy tests can detect pregnancy with a first-morning urine specimen as early as:

Answer 128

7-10 days after ovulation

Urine pregnancy tests determine pregnancy through the detection of the hormone hCG. During pregnancy, the amount of hCG in urine should be around 25 mIU/mL (25 IU/L) at 10 days past ovulation, and 50 mIU/mL (50 IU/L) at 12 days past ovulation. The most sensitive urine pregnancy tests can detect hCG levels as low as 20–25 mIU/mL (20?25 IU/L), though a new version can detect as little as 10 mIU/mL (10 IU/L). In general, testing for pregnancy can begin 7–10 days following ovulation.

Question 129

Most urine pregnancy tests can determine a pregnancy at this level of beta HCG

Answer 129

as low as 20-25 mIU/mL

Question 130

Expected amount of beta hCG in the urine at 10 and 12 days after ovulation

Answer 130

10 days = 25 mIU/mL

12 days = 50 mIU/mL

Question 131

Schedule of 17-a-hydroxyprogesterone (Makena) injections in a pregnant person with singleton and a history of preterm delivery

Answer 131

Weekly injections are initiated between week 16 and week 20 of gestation, and continue until week 37 of gestation.

Question 132

Who is 17-a-hydroxyprogesterone (Makena) indicated for?

Answer 132

17α-hydroxyprogesterone caproate injection (Makena®) is FDA-approved to lower the risk of having a preterm delivery in women who are pregnant with one baby and who have unexpectedly experienced a preterm delivery (before 37 weeks) in the past.

Question 133

When 17α-hydroxyprogesterone caproate injection is used to prevent preterm birth, at what gestational age would you start and stop this therapy?

Answer 133

16-20 weeks until 37 weeks

Question 134

Any postmenopausal bleeding should be evaluated via….

Answer 134

transvaginal ultrasound and/or endometrial biopsy.

Question 135

Appropriate initial management for a 60-year-old female with an atypical squamous cells, cannot exclude high-grade squamous epithelial lesion (ASC-H) Pap test results is:

Answer 135

colposcopy

Atypical squamous cell (ASC) is the most common abnormal finding in Pap tests. ASC can be divided into two categories: 1) atypical squamous cells of undetermined significance (ASC-US) where the squamous cells do not appear completely normal but it is uncertain about what the cell changes mean, and 2) atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion (ASC-H). In ASC-H, the cells do not appear normal and there is uncertainty of the significance of the changes. Follow-up testing in the woman with a finding of ASC-H typically involves colposcopy.

Question 136

The nurse practitioner understands that PMS occurs with greatest frequency and severity in the:

Answer 136

late luteal phase

Symptoms of premenstrual syndrome (PMS) are most prominent during the late luteal phase of the menstrual cycle. The luteal phase begins immediately following the release of the egg from the ovary (ovulation) and lasts from day 14 to day 28 of a normal menstrual cycle. During the luteal phase, progesterone levels increase while estrogen levels decrease. The shift from estrogen to progesterone can cause symptoms related to PMS.

Question 137

According to the American Thyroid Association, the single most reliable test to diagnose all common forms of hyper- and hypothyroidism is ….

Answer 137

a serum TSH measurement (NL=0.4– 4.0 mIU/L)

Question 138

Normal serum TSH

Answer 138

0.4 - 4.0 mIU/L

Question 139

Moderately or severely impaired cardiac function (e.g., peripartum cardiomyopathy) (NYHA III or IV) represents what category on the Medical Eligibility Criteria for IUDs?

Answer 139

category 2 (benefits likely outweigh risks)

Question 140

Moderately or severely impaired cardiac function (e.g., peripartum cardiomyopathy) (NYHA III or IV) represents what category on the Medical Eligibility Criteria for Nexplanon (arm implant)?

Answer 140

category 2 (benefits likely outweigh risks)

Question 141

Moderately or severely impaired cardiac function (e.g., peripartum cardiomyopathy) (NYHA III or IV) represents what category on the Medical Eligibility Criteria for COCs?

Answer 141

category 4 (contraindicated)

Question 142

Endometrial hyperplasia represents what category on the Medical Eligibility Criteria for ALL birth control options

Answer 142

category 1 (no restrictions)

Question 143

History of Roux-en-Y gastric bypass surgery represents what category on the Medical Eligibility Criteria for COCs?

Answer 143

category 3 (risks outweigh the benefits)

Past bariatric surgery that decreases absorption of nutrients by shortening the functional length of the small intestines (e.g., Roux-en-Y gastric bypass) is designated Category 3.

Question 144

Cervical cancer represents what category on the Medical Eligibility Criteria for COCs?

Answer 144

category 2 (benefits usually outweigh the risks)

Question 145

What would you expect to see on labs in subclinical hypothyroidism?

Answer 145

elevated TSH, normal free T4

A subclinical condition is one that is manifested by a pathophysiologic abnormality but not necessarily by clinical signs and symptoms. In subclinical hypothyroidism, there is thyroid hormone production abnormality, usually as a result of primary thyroid failure, that has not yet produced clinical symptoms. As a result, the thyroid stimulating hormone (TSH) level will be elevated, but the circulating free T4 level remains normal due to compensatory mechanisms.

Question 146

When counseling a patient taking levothyroxine (Synthroid®, Levoxyl®), you advise that the medication should be taken…

Answer 146

on an empty stomach at least 2 hours before or after other meals

Levothyroxine is very readily bound to a variety of elements commonly found in food and other medications. As a result, taking exogenous levothyroxine can result in diminished absorption and utilization. The patient can appear unresponsive to therapy. It is important when beginning thyroid hormone replacement therapy that the patient be instructed to take it on an empty stomach, at least 2 hours before or after the last item ingested.

Question 147

Normal range for free T4

Answer 147

0.78‒2.1 ng/d

Question 148

Anticipated lab findings in untreated hyperthyroidism

Answer 148

low TSH, elevated free T4

Question 149

What is the best choice of agents for use in the breastfeeding woman with postpartum depression?

Answer 149

sertraline (Zoloft)

Question 150

What is the best choice for headache control in a woman who is nursing a neonate?

Answer 150

NSAIDs (Ibuprofen) are safe

Question 151

According to Hale, when a medication is categorized as L1 the infant generally receives about ____ of the maternal dose of a drug.

Answer 151

<1%

The relative infant dose (RID) is the term used to describe the percentage of maternal drug dose that is passed to the infant by way of breast milk. The large majority of drugs have an RID =1%. Most drugs with an RID of <10% are considered safe.

Question 152

According to Hale, medications with a relative infant dose (RID) of less than ____% are considered safe during lactation and breastfeeding

Answer 152

<10%

Question 153

For acute onset of severe hypertension of BP >160 mm Hg or diastolic BP >110 mm Hg lasting for >15 minutes in pregnancy or postpartum, first-line treatment is recommended with:

Answer 153

hydralazine 5-10mg IV over 2 minutes

Acute-onset, severe systolic hypertension (>160 mm Hg) or diastolic hypertension (>110 mm Hg) or both can occur in pregnant women or women during the postpartum period. This can occur in the second half of gestation in women not known to have chronic hypertension who develop sudden, severe hypertension (i.e., preeclampsia, gestational hypertension, or HELLP) as well as those with chronic hypertension who are developing superimposed preeclampsia with acutely worsening, difficult to control, severe hypertension. Acute-onset severe intrapartum or postpartum hypertension lasting >15 minutes is considered a hypertensive emergency. As recommended by the American College of Obstetricians and Gynecologists (ACOG), first-line treatment is hydralazine (5 mg or 10 mg IV over 2 minutes).

Question 154

According to the American College of Obstetricians and Gynecologists, a screening clinical breast examination for women should be offered every 1–3 years after what age?

Answer 154

25yo

For women aged 25 to 39 years, ACOG recommends a screening clinical breast examination every 1–3 years. For women aged 40 years and older, ACOG recommends that a clinical breast examination be offered annually.

Question 155

According to the Institute of Medicine (IOM) recommendations for weight gain in pregnancy, a woman with a body mass index (BMI) greater than 30 kg/m² should be advised to gain how much weight over the course of her pregnancy?

Answer 155

11-20lbs

Question 156

According to the Institute of Medicine (IOM) recommendations for weight gain in pregnancy, a woman with a body mass index (BMI) of 25–29.9 kg/m² should be advised to gain how much weight over the course of her pregnancy?

Answer 156

15-25lbs

Question 157

According to the Institute of Medicine (IOM) recommendations for weight gain in pregnancy, a woman with a body mass index (BMI) of 18.5–24.9 kg/m² should be advised to gain how much weight over the course of her pregnancy?

Answer 157

25-35lbs

Question 158

According to the Institute of Medicine (IOM) recommendations for weight gain in pregnancy, a woman with a body mass index (BMI) of <18.5 kg/m² should be advised to gain how much weight over the course of her pregnancy?

Answer 158

28-40lbs

Question 159

Pregnancy complications associated with maternal obesity

Answer 159

• congenital fetal anomalies
• macrosomia
• neonatal hypogylcemia
• stillbirth
• preterm birth
• neonatal and infant mortality
• gestational diabetes
• hypertensive disorders in pregnancy

Question 160

Women who have undergone bariatric procedures should be counseled to avoid pregnancy during the rapid weight loss phase that follows surgery. What is the recommended period that women wait before attempting pregnancy?

Answer 160

12-18 months

Rapid weight loss that follows bariatric surgery can threaten normal development of a fetus during pregnancy. Therefore, contraception and preconception counseling should be provided for all women of reproductive age who are undergoing bariatric surgery. After bariatric surgery, it is recommended that a woman should wait at least 12–18 months before conceiving. Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated as they are at increased risk of deficiencies in iron, vitamin B12, folate, vitamin D, and calcium.

Question 161

Pregnant women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and the need for vitamin supplementation when indicated as they are at increased risk of deficiencies in (5)

Answer 161

• folate
• iron
• B12
• vitamin D
• calcium

Question 162

Some types of bariatric surgical procedures can cause nutritional deficiencies during pregnancy. What vitamins and minerals should be supplemented?

Answer 162

calcium, vitamin D, folic acid, iron, B12

Question 163

According to the American College of Obstetricians and Gynecologists (ACOG), initial screening for an underlying disorder of hemostasis in patients with excessive menstrual bleeding should be structured by the medical history. A positive screening result will include the presence of (3)

Answer 163

1) heavy menstrual bleeding since menarche
2) one of the following conditions: postpartum hemorrhage, surgery-related bleeding, or bleeding associated with dental work
3) two or more of the following: epistaxis (1-2 times per month), frequent gum bleeding, or family history of bleeding symptoms

Question 164

MOA Tranexamic acid (TXA)

Answer 164

Tranexamic acid is an antifibrinolytic agent that works by preventing blood clots from breaking down too quickly, thus reducing excessive bleeding.

Question 165

(3) best birth control types for heavy menstrual bleeding

Answer 165

COCs, DMPA injection, or the levonorgestrel IUD

Question 166

The earliest age that the human papillomavirus vaccination can start is:

Answer 166

9yo

The human papillomavirus vaccine is indicated in males and females as young as 9 years of age and up to 26 years of age. The vaccine is given as a series of 3 injections with the second and third injections administered 2 and 6 months following the initial dose if started after the age of 15. For patients who begin the series before the age of 15, the vaccine is given in a series of 2 injections at 0 and 6 months.

Question 167

2-series HPV vaccine schedule for those 9-15yo

Answer 167

baseline and 6 months later

Question 168

The 9-valent HPV vaccine provides protection against HPV types implicated in approximately _______ of cervical, vulvar, vaginal, and anal cancers.

Answer 168

90%

Human papillomaviruses are a collection of over 150 viruses, 40 of which are sexually transmitted. Of all of the sexually transmitted types, HPV type 16 and HPV type 18 have been implicated in approximately 70% of cervical neoplasms. The original FDA approved quadrivalent HPV vaccine provided protection against HPV types 6, 11, 16 and 18. The nine-valent HPV vaccine provides protection against 5 additional types (31, 33, 45, 52, and 58). The 9-valent vaccine has the potential to prevent approximately 90% of cervical, vulvar, vaginal, and anal cancers.

Question 169

% of cervical cancers caused by HPV types 16 and 18

Answer 169

70%

Question 170

Which vaccine(s) are recommended during pregnancy to achieve passive immunity in the newborn?

Answer 170

Tdap (27 weeks)
influenza (any trimester)

During pregnancy, it is recommended that women receive vaccinations against influenza (injectable vaccine formulation) and Tdap. These vaccines do not contain live virus and so there is no threat to pass the virus to the fetus. The MMR (measles, mumps, and rubella) and varicella vaccines are live attenuated virus preparations, and are not recommended during pregnancy due to the risk of passing the virus to the fetus.

Question 171

Definition of a full-term pregnancy is one that is delivered at:

Answer 171

39 0/7 to 40 6/7

A full-term pregnancy is one that is delivered at 39 weeks through 40 weeks plus 6 days. An early-term pregnancy is delivered at 37 weeks through 38 weeks plus 6 days. A late-term pregnancy occurs at 41 weeks through 41 weeks plus 6 days. A delivery occurring at 42 weeks and beyond is a postterm pregnancy.

Question 172

Definition of an early-term pregnancy is one that is delivered at:

Answer 172

37 0/7 - 38 6/7

Question 173

Definition of a late-term pregnancy is one that is delivered at:

Answer 173

41 0/7 - 41 6/7

Question 174

Definition of a post-term pregnancy is one that is delivered at:

Answer 174

42 0/7 or later

Question 175

Several factors have been identified that increase the risk of cervical cancer in women with HPV. The most significant factors include (2)

Answer 175

cigarette smoking, DES exposure

cigarette smoking and exposure to diethylstilbestrol (DES). DES exposure occurred in women whose mothers took DES while pregnant (between 1938 and 1971) for the prevention of spontaneous abortion or preterm labor.

Question 176

DES exposure occurred in folks whose mothers took DES while pregnant between _____ and ____ for the prevention of SAB or preterm labor

Answer 176

1938-1971

Question 177

A 20-year-old female of European ancestry with mixed IBS (constipation and diarrhea) symptoms who has not been out of country should be tested for ….

Answer 177

celiac disease via serologic screening

Celiac disease is an autoimmune disorder that causes the immune system to interfere with the proper function of the small intestines when a person ingests gluten. The symptoms of celiac disease often mimic other diseases, such as irritable bowel disease, Crohn’s disease, and diverticulitis, and so a serological assay to detect for the presence of autoantibodies can be used to confirm a celiac diagnosis. Celiac disease is most commonly found in Caucasians and persons of European ancestry.

Question 178

What is celiac disease?

Answer 178

Celiac disease is an autoimmune disorder that causes the immune system to interfere with the proper function of the small intestines when a person ingests gluten.

Question 179

How is celiac disease diagnosed?

Answer 179

serological assay to detect for the presence of autoantibodies can be used to confirm a celiac diagnosis.

Question 180

Racial/ethnic groups most at risk for celiac disease

Answer 180

Caucasian, European

Question 181

Rome II Criteria for the diagnosis of IBS

Answer 181

• abdominal discomfort or pain
• lasting at least 12 weeks (which need not be consecutive) in the preceding 12 months
• with 2 or more of the following:
  1) relieved with defecation, and/or
  2) onset associated with a change in frequency of stool, and/or
  3) onset associated with a change in form (appearance) of stool.

Question 182

A 16-year-old G1 P0 at 14 weeks gestation has experienced severe nausea and vomiting since the start of the pregnancy. She was initially prescribed promethazine (Phenergan®) by mouth which was not effective and was switched to ondansetron (Zofran®) but reports continued nausea and vomiting 1–2 hours after eating. She has had a 4-lb (1.81-kg) weight gain since the start of the pregnancy and does not appear to be dehydrated. Urine specific gravity was 1.020 and fundal height measured appropriately. Patient denies signs and symptoms of GERD or upper abdominal pain. Vital signs are WNL. No evidence of vomiting during the hour that the patient was in the office. What do you recommend?

Answer 182

• eating small frequent meals
• snacks high in protein
• avoid fatty or acidic foods
• ginger before bed (ginger lollipops or ginger supplements 250 mg PO QID)
• vitamin B6 (pyridoxine) and/or doxylamine (Diclegis; Bonjesta)

Question 183

Ginger recommendations for n/v in pregnancy

Answer 183

ginger supplements 250mg PO up to QID

Question 184

A 24-year-old G1 P0 client at 39 weeks gestation presents for delivery. She has a history of genital herpes and has been taking prophylactic therapy for the past 3 weeks. She desires a natural vaginal delivery. A perineal exam identifies the presence of multiple vesicular lesions. You counsel her that:

Answer 184

C-section is recommended to minimize risk of perinatal transmission

Women with genital herpes during pregnancy can pose a risk of transmitting the infection to the newborn. Infection most often occurs as the baby passes through an infected birth canal, and infection can cause serious complications to a newborn, including brain damage and ocular problems. If a vaginal delivery is desired by the mother, antiviral prophylaxis (e.g., acyclovir, famciclovir, valacyclovir) should be initiated at 36 weeks gestation. When the mother presents for delivery, if no lesions are present in the birth canal, a cesarean is not necessary and a vaginal delivery is possible.

Question 185

What/when should you prescribe for a pregnant person with genital HSV who desires a vaginal birth

Answer 185

antiviral prophylaxis (acyclovir, famiciclovir, valacyclovir) initiated at 36 weeks

Question 186

What are the three stages of labor?

Answer 186

Childbirth occurs in three stages.

1. The first stage of labor is usually the longest and lasts from the time of onset of labor (i.e., regular contractions) until the cervix is completely dilated to 10 cm.
2. The second stage comprises the period after the cervix is fully dilated until the baby is delivered.
3. The third stage involves the delivery of the placenta.

Question 187

First stage of labor

Answer 187

onset of regular contractions until the cervix is dilated to 10 cm

Question 188

Second stage of labor

Answer 188

from complete cervical dilation to delivery of the baby

Question 189

Third stage of labor

Answer 189

from delivery of the baby to delivery of the placenta

Question 190

A 27-year-old G2 P1 had a C-section with her last delivery because of a transverse lie. She relates that they told her that the baby “was stuck” in the top part of her uterus and they had to “do an extra cut up there” to get him out. She is interested in having a vaginal birth after cesarean section (VBAC) with this pregnancy. You tell her that:

Answer 190

she may not be a candidate for TOLAC if the record confirms her history

A trial of labor after previous cesarean delivery (TOLAC) can allow women who desire a vaginal delivery the possibility of achieving this goal. Although TOLAC can be appropriate for many women, several factors increase the risk of failure. These include a recurrent indication for initial cesarean delivery (e.g., labor dystocia), increased maternal age, non-white ethnicity, gestational age >40 weeks, maternal obesity, preeclampsia, shorter interpregnancy interval, and increased neonatal birth weight. The type of uterine incision(s) performed during the prior cesarean can increase the risk of uterine rupture or maternal or perinatal morbidity associated with TOLAC. Women at high risk for complications include those with a previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery, and TOLAC should not be considered for these patients

Question 191

Magnesium sulfate indications in pregnancy

Answer 191

• neuroprotection in pre-eclampsia

- tocolytic in PTL

Question 192

mag toxicity include (3)

Answer 192

• hypotension
• circulatory collapse
• CNS depression (e.g., absent DTRs)

Question 193

Mag cannot be used for longer than ______ as a tocolytic for PTL due to the risks of (2)

Answer 193

• 5-7 days

- fetal hypocalcemia and skeletal abnormalities (e.g., bone demineralization)

Question 194

Risk factors for polyhydramnios include……

Answer 194

• fetal congenital GI defect
• fetal CNS defect
• maternal diabetes
• twin-twin transfusion syndrome
• fetal anemia
• ABO incompatibility

Question 195

According to Fitzgerald, a normal value at 1-hour post-50-g OGTT is ….

Answer 195

≤140 mg/dL (7.8 mmol/L)

Question 196

About___% of women with a positive 1-hr OGTT screen who take the 3-hour OGTT will not have gestational diabetes.

Answer 196

66%

Question 197

A gravid client has been diagnosed with gestational diabetes. After a trial of diet and exercise, she still remains hyperglycemic. Which of the following is the least appropriate treatment option of insulin, sulfonylurea, metformin, or SGLT2?

Answer 197

SGLT2

Up to 7% of pregnancies are complicated by diabetes mellitus, with the majority due to gestational diabetes. Nutritional counseling with physical activity is the preferred first-line management option for women diagnosed with gestational diabetes. If medications are needed, insulin and oral medications are equally effective and appropriate. A woman with gestational diabetes should be screened again at 6 to 12 weeks postpartum. The SGLT2 inhibitor, dapagliflozin (Farxiga®), is Pregnancy Category C and use should be deferred over other options with more established safety profiles among pregnant women.

Question 198

Insulin needs increase during pregnancy due to physiologic increased insulin resistance, largely under the influence of this hormone….

Answer 198

human placental lactogen (hPL)

Human placental lactogen (hPL) is a hormone produced by the placenta that helps to break down fats (lipolysis) from the mother to release free fatty acids for fuel for the growing fetus. The hormone decreases maternal insulin sensitivity, leading to an increase in maternal blood glucose levels. As a result, for mothers requiring insulin to treat diabetes mellitus, a higher dose will be needed to maintain glucose control, particularly starting around the 24th week of gestation.

Question 199

Around what week of gestation do we expect insulin needs to begin to increase for those with gestational diabetes

Answer 199

24 weeks

Human placental lactogen (hPL) is a hormone produced by the placenta that helps to break down fats (lipolysis) from the mother to release free fatty acids for fuel for the growing fetus. The hormone decreases maternal insulin sensitivity, leading to an increase in maternal blood glucose levels. As a result, for mothers requiring insulin to treat diabetes mellitus, a higher dose will be needed to maintain glucose control, particularly starting around the 24th week of gestation.

Question 200

Criteria for a reactive NST

Answer 200

The test is reactive if the fetal heart beats faster (≥15 bpm for at least 15 seconds) when the baby moves, which must happen at least 2 times in 20 minutes. The test is nonreactive if the fetal heart does not beat faster when the baby moves or if the baby is quiet and not moving.

Question 201

Umbilical cord prolapse (UCP) is an obstetric emergency in which the cord passes through the cervix at the same time or in advance of the presenting fetus. Compression of the cord can then lead to fetal hypoxia. A membrane rupture is the precipitating event for a prolapsed cord. Factors that can increase the risk of cord prolapse include (5)

Answer 201

• malpresentation (e.g., breech)
• fetal anomalies
• prematurity
• polyhydramnios
• multiple gestation.

Question 202

An 18-year-old presents 6 weeks following delivery of a healthy term baby and complains of intermittent palpitations, anxiety, tremors, and feeling warm more often. You consider a likely diagnosis to be:

Answer 202

postpartum thyroiditis

Postpartum thyroiditis occurs when a normally-functioning thyroid gland becomes inflamed within the first year after childbirth. Symptoms of postpartum thyroiditis are similar to hyperthyroidism and include anxiety, irritability, palpitations, unexplained weight loss, increased sensitivity to heat, fatigue, tremor, and insomnia. Symptoms typically occur 1–4 months after delivery.

Question 203

Screen all folks for GDM at this time period

Answer 203

24-28 weeks

Question 204

Counseling on alcohol use during pregnancy

Answer 204

Pregnant women are urged not to consume alcohol as it can affect development of the fetus and lead to long-term medical problems and birth defects. Complications related to alcohol use during pregnancy include cerebral palsy, premature delivery, miscarriage, or stillbirth. There is no known “safe” amount of alcohol use during pregnancy. Alcohol is metabolized much more slowly in the baby compared to an adult, thus alcohol remains in the baby for a longer time compared to the mother. Alcohol use appears to be most harmful during the first trimester; however, drinking alcohol anytime during pregnancy can be harmful.

Question 205

substances that remain in higher concentration in the fetus compared to the mother (2)

Answer 205

alcohol, tobacco

Alcohol is metabolized much more slowly in the baby compared to an adult, thus alcohol remains in the baby for a longer time compared to the mother

Question 206

Alcohol use appears to be most harmful during the ______ trimester; however, drinking alcohol anytime during pregnancy can be harmful.

Answer 206

first trimester

Question 207

You have just completed health history of a 22-year-old primigravida client at her first prenatal visit and discovered that she is diagnosed with phenylketonuria. An appropriate immediate next step is to:

Answer 207

• refer for nutritional counseling

Phenylketonuria (PKU) is an autosomal recessive disorder characterized by a deficiency of the hepatic enzyme, phenylalanine hydroxylase, which is responsible for the conversion of phenylalanine to tyrosine. Women with PKU are strongly encouraged to receive family planning and preconception counseling and should begin appropriate, medically-directed dietary phenylalanine restriction before conception.

Question 208

Risks for children born to mothers with PKU who were on unrestricted diets (3)

Answer 208

• developmental disability (>90%)
• microcephaly (>70%)
• congenital heart defects (12%)

Question 209

Primary amenorrhea is when a patient has one of (3) :

Answer 209

• normal secondary sex characteristics but no menarche by age 16yo
• no menstruation by 4 years after thelarche
• no secondary sex characteristic development including no menarche by 14yo

Question 210

What is Turner Syndrome?

Answer 210

45X, aka gonadal dysgenesis

Turner syndrome occurs when a female is missing all or part of an X chromosome. Signs of Turner syndrome in adolescents and young adults include short stature, learning disabilities, failure to begin sexual changes expected during puberty, or sexual development “stalls” during teenage years.

Question 211

Signs of Turner Syndrome

Answer 211

• short stature
• learning disabilities
• failure to begin secondary sex changes associated with puberty
• sexual development “stalls” during the teenage years

Question 212

The most common cause of new-onset secondary amenorrhea is:

Answer 212

pregnancy

Pregnancy is the most common reason for secondary amenorrhea.

Question 213

Definition of amenorrhea

Answer 213

absence of menses for …
1) three menstrual cycles or a total of 6 months in women who have previously had normal menstruation,
OR
2) duration of 3 typical menstrual cycles with oligomenorrhea (defined as cycle lengths >40 days but less than 6 months).

Question 214

Definition of oligomenorrhea

Answer 214

cycle lengths >40 days but less than 6 months

Question 215

A young woman with primary amenorrhea and normal secondary sex characteristics is being evaluated. Pregnancy has been ruled out. The progesterone challenge test can be conducted to determine the presence of:

Answer 215

endogenous estrogen

The progesterone challenge test (also known as the progesterone withdrawal test) can be used as a bioassay to demonstrate estrogen effect at the level of the endometrium. Progesterone predictably induces a withdrawal bleed if the circulating serum estradiol level is at least 50 pg/mL (184 pmol/L).

Question 216

In the progesterone challenge test, progesterone administration and withdrawal predictably induces a withdrawal bleed if the circulating serum estradiol level is at least……

Answer 216

50 pg/mL

Question 217

What is the primary function of FSH?

Answer 217

stimulation of mature ovarian follicles

In women, follicle stimulating hormone (FSH) stimulates the growth of ovarian follicles in the ovary before the release of the egg at ovulation. Ovulation is then induced by a burst of luteinizing hormone (LH).

Question 218

You are seeing a 4-day postpartum breastfeeding client in the office for complaints of painful nipples. You examine her breasts and notice blood on the mother’s breast pad and a crack on the mother’s nipple. You recommend:

Answer 218

• Continue breastfeeding (do not discontinue)
• Recommend that she apply a small amount of lanolin to each nipple after each feeding.
• Take an oral analgesic 30 minutes prior to breastfeeding.
• After breastfeeding, cleanse the nipples gently with plain water
• Once daily, cleanse the nipples with a small amount of non-bacterial and non-perfumed soap

Painful cracked and bleeding nipples are not a normal part of breastfeeding and can be an indication of an improper latch or using a breast pump improperly. Breastfeeding should not be discontinued at this time, but an oral analgesic can be taken about 30 minutes prior to nursing to alleviate pain. After breastfeeding, the nipples should be cleaned gently with water. Once daily, the nipples should be cleaned with a small non-antibacterial and non-perfumed soap. Use of medical-grade lanolin on the nipples after every feeding will help to relieve pain and allow the wound to heal faster without forming a scab.

Question 219

Painful cracked and bleeding nipples [are vs. are not] a normal part of breastfeeding

Answer 219

not normal

Painful cracked and bleeding nipples are not a normal part of breastfeeding and can be an indication of an improper latch or using a breast pump improperly.

Question 220

A 22-year-old female presents for her annual examination. She relates that due to religious beliefs, she prefers not to use contraceptive via medications or barrier method. She has several questions related to fertility awareness and the time when she is least likely to get pregnant. You advise her that she is least fertile when her cervical mucus is:

Answer 220

opaque, thick, sticky at the time that it is under the influence of progesterone

Progesterone confers a contraceptive effect by causing a thickening of the cervical mucus that inhibits sperm migration. Estrogen causes a thinning of and increased production of cervical mucus, thus facilitating sperm migration to the ova. The mucus at this stage is described as clear, watery, and stretchy.

Question 221

You examine a 24-year-old woman who is 26-weeks pregnant and has an acute asthma flare. Her medication regimen should be adjusted to include:

Answer 221

prednisone

A pregnant woman experiencing an acute asthma exacerbation needs to be placed immediately on a systemic steroid regimen. Prednisone is pregnancy category C where adverse effects have been observed in animal studies but there are no adequate, well-controlled studies in humans; potential benefits often warrant use in pregnant women. Irrespective of the pregnancy category, neither salmeterol nor montelukast are appropriate treatments for an acute asthma exacerbation.

Question 222

A pregnant woman experiencing an acute asthma exacerbation needs to be placed immediately on a ______ regimen.

Answer 222

systemic steroid

Question 223

The cornerstone controller therapy for chronic persistent asthma during pregnancy is the use of:

Answer 223

inhaled corticosteroids

During pregnancy, the main goal of asthma treatment is to maintain sufficient oxygenation of the fetus by preventing hypoxic episodes in the mother. For persistent asthma during pregnancy, the American College of Obstetricians and Gynecologists (ACOG) recommend first-line controller therapy with inhaled corticosteroids. Inhaled albuterol (a short-acting beta2- adrenergic agonist) is the preferred rescue therapy for women who are pregnant.

Question 224

The cornerstone rescue therapy for chronic persistent asthma during pregnancy is the use of:

Answer 224

inhaled albuterol (SABA)

During pregnancy, the main goal of asthma treatment is to maintain sufficient oxygenation of the fetus by preventing hypoxic episodes in the mother. For persistent asthma during pregnancy, the American College of Obstetricians and Gynecologists (ACOG) recommend first-line controller therapy with inhaled corticosteroids. Inhaled albuterol (a short-acting beta2- adrenergic agonist) is the preferred rescue therapy for women who are pregnant.

Question 225

MOA RhoGAM

Answer 225

RH immune globulin (human) (RhoGAM®) contains antibodies against the Rh D factor that destroys any red blood cells from the baby that have entered the mother’s blood, and thus will prevent the mother from producing her own antibodies and developing Rh sensitivity

Question 226

A pregnant woman presents to the office complaining of bleeding and cramping. The initial history is significant for a last menstrual history of six weeks ago. The hCG is positive and the cervix is closed. You would most likely suspect:

Answer 226

threatened abortion

Threatened abortion is a diagnosis made during the first 20 weeks of pregnancy and can include symptoms of bleeding and abdominal cramping without signs of cervical change and no passage of products of conception. Threatened abortion indicates a higher risk of miscarriage, though in many cases, the cause of bleeding is due to a minor condition that requires no treatment. Possible causes of bleeding include implantation of embryo, infection, irritation, miscarriage, ectopic pregnancy, or molar pregnancy.

Question 227

Define threatened abortion

Answer 227

<20 weeks EGA
symptoms of bleeding and abdominal cramping
NO signs of cervical change
NO passage of the products of conception

Question 228

Cell-free DNA screening is a test that can determine if a woman has a higher chance of having a fetus with: (4)

Answer 228

• down syndrome (trisomy 21)
• trisomy 18
• trisomy 13
• abnormality of the sex chromosomes

Question 229

Cell-free DNA screening can be drawn when

Answer 229

after 10 weeks gestation

Question 230

msAFP screening can be drawn when

Answer 230

15-22 weeks gestation (typically as part of the quad screen, or as a stand-alone if they already had the first trimester triple screen) … though most accurate between 16-18 weeks

Question 231

Increased msAFP can mean….

Answer 231

• Absence of part of the brain and skull (anencephaly)
• Defect in the baby’s intestines or other nearby organs (such as duodenal atresia)
• Death of the baby inside the womb (usually results in a miscarriage)
• Spina bifida (spinal defect)
• Tetralogy of Fallot (heart defect)
• Turner syndrome (genetic defect)
• Multiple gestation

Question 232

Decreased msAFP can mean…..

Answer 232

• Trisomy 21 (Down’s syndrome)

- Trisomy 18

Question 233

When is a nuchal translucency test performed

Answer 233

10-13 weeks

Question 234

When can CVS be performed

Answer 234

10-12 weeks

Question 235

When can amniocentesis be performed

Answer 235

15-20 weeks

Question 236

Immediate diagnostic work-up for pre-eclampsia with possible severe features on mom

Answer 236

should include complete CBCs, LFTs, uric acid, and 24-hour urine collection for protein.

Question 237

Typically, zidovudine (azidothymidine or AZT) in combination with other medications for HIV are initiated in a newly-diagnosed HIV positive pregnant woman at what gestational age?

Answer 237

14 weeks

During pregnancy, all women with HIV are advised to take combination antiretroviral regimens using 3 drugs. When possible, zidovudine is included because it has been shown to significantly reduce the risk of passing the HIV virus to the infant. Zidovudine is often started at 14 weeks gestation to avoid exposing the fetus to medications during the first trimester.

Question 238

Your pregnant patient asks you what is toxoplasmosis

Answer 238

Toxoplasmosis is caused by an infection from the protozoan, Toxoplasma gondii. Most people with toxoplasmosis do not experience any signs or symptoms of infection, though some can experience flu-like symptoms. However, during pregnancy, infection of the fetus can cause stillbirth and miscarriage. Children born with toxoplasmosis (congenital toxoplasmosis) are also more likely to have seizures, enlarged liver or spleen, jaundice, and severe eye infections. The baby is at greatest risk if the infection occurs during the third trimester, and there is the least risk with infection during the first trimester. The parasite can be transmitted via contact with infected cat feces (e.g., changing the litter box).

Question 239

Toxoplasmosis is most vs. least risky for the fetus when acquired in which trimesters

Answer 239

most risk = third trimester

least risk = first trimester

Question 240

You are counseling a patient who is 6-weeks pregnant. She is worried about being exposed to harmful infections since she is a kindergarten teacher. She reports having rubella and chicken pox as a child and is up-to-date on immunizations. You would correctly advise her that the most harmful and most probable risk of exposure would be to:

Answer 240

CMV

Transmission of cytomegalovirus (CMV) occurs from person to person and, though not highly contagious, is more likely to occur in households and settings with young children. Though a primary CMV infection does not typically affect the mother, the virus can be transmitted to the fetus and cause complications, including ocular problems and seizures.

Question 241

Menstrual cycle length greater than __________months should be evaluated even in adolescents.

Answer 241

> 3 months

A menstrual cycle interval or more than 90 days for a post-menarchal girl or a reproductive-aged woman is statistically unusual. In these cases, further evaluation should be conducted to identify the cause.

Question 242

Quad screen results suggestive of Trisomy 21 (Down Syndrome)

Answer 242

Trisomy 21 is suggested with findings of:

• increased levels of inhibin A
• increased hCG
• decreased levels of msAFP
• decreased levels of uE3 (estriol)

Question 243

Trisomy 21

Answer 243

Down’s syndrome

Question 244

Trisomy 18

Answer 244

Edward’s syndrome

Question 245

Trisomy 13

Answer 245

Patau syndrome

Question 246

When is the quad screen drawn

Answer 246

in the second trimester, typically 15-21 weeks

Question 247

Quad screen results suggestive of neural tube defect (NTD)

Answer 247

Neural tube defect is suggested with findings of:

• increased level of msAFP
• normal levels of inhibin A
• normal hCG
• normal uE3 (estriol)

Question 248

You see an 18-year-old female who desires to start combined oral contraceptives (COC). Her LMP was 6 days ago and you are reasonably certain she is not pregnant, after discussing various options she decides to initiate COCs today. Once she starts her regimen, you advise that she does or does not need back-up protection and for how long?

Answer 248

use backup protection for 7 days

There are a variety of methods to start COC that may or may not require the use of a backup method. If COC is initiated on the first five days of the menstrual period, no backup method is needed; back up method for 7 days is required for any COC started after the fifth day of the menstrual period. COC can also be initiated the day after taking emergency contraception with use of a backup for 7 days.

Question 249

If a new COC method is initiated on the first _____ days of the menstrual period, no back-up method is needed. If started at any other time, use back-up for ______ days

Answer 249

first 5 days of menses

otherwise backup for 7 days

Question 250

Folks for whom post-menopausal HT may not be a good idea

Answer 250

• history of breast or endometrial cancer,
• thromboembolic disorders,
• undiagnosed vaginal bleeding,
• endometriosis,
• fibroids