Question 1

An adolescent female has heavy periods that are also irregular. The physical exam is normal. A complete blood count reveals a hemoglobin of 8.9 g/dL. What test will the primary care pediatric nurse practitioner order next?

A) Coagulation studies
B) C-reactive protein
C) Thyroid function
D) Ultrasound of pelvis

A

Accepted Answer

A

Question 2

An adolescent female tells the primary care pediatric nurse practitioner that she had unprotected sexual intercourse 4 days prior and is worried she might become pregnant. What will the nurse practitioner do?

A) Prescribe ulipristal acetate
B) Recommend levonorgestrel
C) Start a combination OCP at regular doses.
D) Suggest using the less expensive After Pill preparation.

A

Accepted Answer

Ulipristal acetate is effective for up to 5 days after unprotected intercourse, making it the best option in this scenario.

Question 3

The primary care pediatric nurse practitioner is prescribing contraception for an adolescent who has not used birth control previously. The adolescent has a normal exam and has no family history of cardiovascular and peripheral vascular disease or diabetes. Which preparation is used initially?

A) A combination oral contraceptive pills (OCP) with 30 to 35 mcg of estrogen and low progestin
B) A combination OCP with low androgenic potency, such as Ortho-Cyclen
C) A progestin-only mini-pill oral contraceptive
D) A subdermal implant contraception, such as Implanon or Nexplanon

A

Accepted Answer

Combination oral contraceptive pills with 30 to 35 mcg of estrogen and low progestin are typically used initially for adolescents starting contraception, as they are effective and have a favorable side effect profile.

Question 4

A 15-year-old female has a positive pregnancy test and asks the primary care pediatric nurse practitioner not to tell her parents. She is tearful and says she isn't sure she wants to keep the baby. What will the nurse practitioner do first?

A) Determine the state-mandated reporting laws.
B) Encourage the adolescent to talk to her parents.
C) Obtain a social work consult to discuss adoption options.
D) Refer her to a prenatal care specialist for follow-up.

Accepted Answer

The first priority for the nurse practitioner is to determine the state-mandated reporting laws regarding underage pregnancy. This will inform the nurse practitioner of their legal obligations and help protect the patient's confidentiality as much as possible. Encouraging the adolescent to talk to her parents or discussing adoption options may be appropriate later but should not be the first action taken without understanding reporting laws. Referring her to a prenatal care specialist for follow-up is also important but should come after determining reporting laws.

Question 5

A 16-year-old female has not had a menstrual period yet and is concerned. She denies sexual activity. An exam reveals an adult sexual maturity rating. Which laboratory test will the primary care pediatric nurse practitioner order initially?

A) Genetic test for Turner syndrome
B) Pituitary hormone tests
C) Pregnancy test
D) Thyroid function tests

Accepted Answer

The first step in evaluating a delayed or absent menstrual period in a female who denies sexual activity is to rule out pregnancy. A pregnancy test should be ordered initially before considering other causes such as genetic or endocrine issues.

Question 6

A 17-year-old sexually active female who began having periods at age 14 reports having moderate to severe dull lower abdominal pain associated predominantly with periods but that occurs at other times as well. The history reveals a recent onset of these symptoms. A pregnancy test is negative. Which course of action is most important?

A) Perform a full diagnostic workup to evaluate potential causes.
B) Prescribe a prostaglandin synthetase inhibitor.
C) Start a 3- to 6-month trial of oral contraceptive pills.
D) Suggest using transcutaneous electrical nerve stimulation.

Accepted Answer

Given the recent onset of moderate to severe dull lower abdominal pain that occurs predominantly with periods but also at other times, and considering the patient's age and sexual activity, a full diagnostic workup is crucial to evaluate potential causes. This approach is important to rule out conditions such as endometriosis, pelvic inflammatory disease, or other gynecological issues that could be causing her symptoms.

Question 7

A sexually active adolescent female tests positive for N. gonorrhoeae and C. trachomatis. She tells the primary care pediatric nurse practitioner that she wants to be treated today since she is moving out of town the next day. What will the nurse practitioner order?

A) Azithromycin 1 g PO in a single dose
B) Ceftriaxone 250 mg IM and azithromycin 1 g PO one time each
C) Doxycycline 100 mg PO bid for 7 days
D) Erythromycin base 500 mg PO qid for 7 days

Accepted Answer

Combination therapy with ceftriaxone and azithromycin is the recommended treatment for gonorrhea and chlamydia co-infection according to the CDC guidelines. A single dose of ceftriaxone 250 mg IM and azithromycin 1 g PO one time each is effective treatment and allows for quick resolution of symptoms.

Question 8

A 16-year-old female reports breast tenderness and a "lump." The primary care pediatric nurse practitioner palpates a small fluid-filled mass in her right breast. A pregnancy test is negative. Which action is correct?

A) Obtain a CBC to rule out infection.
B) Order an ultrasound of the mass.
C) Prescribe NSAIDs to treat her discomfort.
D) Reassure her that the findings are normal.

Accepted Answer

Given the patient's age and negative pregnancy test, it is important to rule out any potential malignancy with an ultrasound of the mass. While a CBC may be indicated if an infection is suspected, there is no current evidence to suggest that is the case. NSAIDs can help with discomfort, but do not address the underlying cause of the mass. Reassuring the patient without further evaluation would be inappropriate as a small percentage of breast masses in adolescents may be malignant.

Question 9

A 16-year-old female reports dull, achy cramping pain in her lower abdomen lasting 2 or 3 hours that occurs between her menstrual periods each month. The adolescent is not sexually active. What is the treatment for this condition?

A) Abdominal ultrasound to rule out ovarian cyst
B) Oral contraceptives to suppress ovulation
C) Prostaglandin inhibitor analgesics and a heating pad
D) Referral to a pediatric gynecologist

Accepted Answer

The symptoms described are consistent with dysmenorrhea, which is common in adolescent females. The treatment is usually to manage pain and discomfort with prostaglandin inhibitor analgesics (such as ibuprofen) and a heating pad. Ovarian cysts are a possibility, but an abdominal ultrasound would not be the initial diagnostic test. Oral contraceptives may be helpful in managing dysmenorrhea, but they are usually not the first line of treatment. Referral to a pediatric gynecologist may be considered if the symptoms are severe or do not respond to initial treatment.

Question 10

A 16-year-old sexually active female has a fever, bilateral lower abdominal pain, and malaise. A speculum and bimanual exam reveals adnexal tenderness. The urinalysis is normal and cervical cultures are pending. What medications will the primary care pediatric nurse practitioner prescribe for this patient?

A) Azithromycin, doxycycline, and penicillin
B) Cefotaxime, azithromycin, and penicillin
C) Ceftriaxone, doxycycline, and metronidazole
D) Doxycycline, penicillin, and metronidazole

Accepted Answer

The patient's symptoms and exam findings are suggestive of pelvic inflammatory disease (PID), which is commonly caused by sexually transmitted infections (STIs) such as chlamydia and gonorrhea. Therefore, a combination of antibiotics that cover these pathogens is necessary. Ceftriaxone and azithromycin are effective against gonorrhea and chlamydia, respectively, while doxycycline is effective against both. Metronidazole is included to cover anaerobic bacteria that may also be present in PID. Penicillin is not effective against these pathogens and is not typically used for PID. Cefotaxime is not the best choice as it is primarily used for severe infections and there is not enough information to suggest that the patient is experiencing a severe infection.

Deck 42: Pediatric and Adolescent Gynecology