Deck 19: The Pregnant Woman

Question 1

A 29-year-old homemaker who is G4P3 comes to your clinic for her first prenatal check. Her last period was 2 months ago. She has had three previous pregnancies and deliveries with no complications. She has no medical problems and has had no surgeries. Her only current complaint is of severe reflux that occurs in the mornings and evenings. On examination she is in no acute distress. Her vitals are 110/70 with a pulse of 88. Her respirations are 16. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On bimanual examination her cervix is soft and her uterus is 10 weeks in size. Pap smear, cultures, and blood work are pending. What is the most likely cause of her first-trimester reflux?

A) Increasing prolactin levels
B) Increasing ADH (antidiuretic hormone) levels
C) Increasing progesterone
D) Enlarged gravid uterus

Answer 1

Increasing progesterone

Question 2

A 26-year-old telephone operator comes to your office for her first prenatal visit. This is her first pregnancy. Her last period was about 2 months ago. She has no current complaints. She is eating healthily, taking vitamins, and exercising. She has a past medical history of an appendectomy as a teenager. Her mother had three children vaginally with no complications. On examination she appears healthy and her vital signs are unremarkable. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are also unremarkable. By speculum examination, her cervix appears bluish in color and highly vascular. A bimanual examination reveals a soft cervix and a 12-week-sized uterus. No masses are felt in either adnexal area. Results of her Pap, cultures, and blood work are pending. What clinical sign is responsible for her blue, highly vascular cervix?

A) Chadwick's sign
B) Hegar's sign
C) Leopold's sign
D) Leo's sign

Answer 2

Chadwick's sign

Question 3

A 22-year-old clerk, primigravida, comes to your office for a prenatal visit. She is in her second trimester and has had prenatal care since she was 8 weeks pregnant. Her only complaint is that she has a new brownish line straight down her abdomen. On examination her vital signs are unremarkable. Her urine has no protein, glucose, or leukocytes. With a Doptone the fetal heart rate is 140, and her uterus is palpated to the umbilicus. Today you are sending her for congenital abnormality screening and setting up an ultrasound. What physical finding is responsible for her new "brown line"?

A) Corpus luteum
B) Linea nigra
C) Linea alba
D) Diastasis recti

Answer 3

Linea nigra

Question 4

A 20-year-old college student comes in with symptoms of fatigue, nausea, and an increase in urination. Her last period was 3 months ago (June 20, 2008). She is sexually active and always uses condoms. Her past medical history is unremarkable. On examination you see a young, anxious-appearing woman. Her vital signs are unremarkable. Her head, eyes, ears, throat, neck, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On pelvic examination a soft cervix is palpated and a 14-week-sized uterus is palpated. A urine pregnancy test is positive. You then inform the patient that she is expecting and, using Naegele's rule, give her the estimated date of confinement (EDC, or due date). What was the due date you gave her?

A) March 27, 2009
B) March 13, 2009
C) September 27, 2009
D) March 20, 2009

Question 5

A 19-year-old childcare worker comes to you for her first prenatal visit. She cannot remember when her last period was but thinks it was between 2 and 5 months ago. When she began gaining weight and feeling "something" moving down there, she did a home pregnancy test and it was positive. She states she felt the movement about a week ago. She has had no nausea, vomiting, fatigue, or fevers. Her past medical history is remarkable only for irregular periods. She has been dating the same young man for a year. She says they were not using condoms. On examination you see an overweight young lady appearing her stated age. Her head, eyes, ears, nose, throat, neck, thyroid, cardiac, and pulmonary examinations are unremarkable. Her abdomen is nontender, with normal bowel sounds, and the gravid uterus is palpated to the level of the umbilicus. Fetal tones are easily found with Doptone, and with the fetoscope a faint heart rate of 140 is heard. By speculum examination the cervix is bluish and by bimanual examination the cervix is soft. Results of Pap smear, cultures, and blood work are pending. You give the patient her due date and how far along she is, based on your clinical findings. An OB ultrasound to confirm her dates is ordered. With only the clinical examination, how many weeks pregnant did you tell this patient she is?

A) 6 to 8 weeks
B) 12 to 14 weeks
C) 18 to 20 weeks
D) 24 to 26 weeks

Question 6

A 32-year-old attorney comes to your office for her second prenatal visit. She has had two previous pregnancies with uneventful prenatal care and vaginal deliveries. Her only problem was that with each pregnancy she gained 50 lbs (23 kg) and had difficulty losing the weight afterward. She has no complaints today. Looking at her chart, you see she is currently 10 weeks pregnant and that her prenatal weight was 130 lbs (59 kg). Her weight today is 134 lbs (60.9 kg). Her height is 5'4", giving her a BMI of 22. Her blood pressure, pulse, and urine tests are unremarkable. The fetal heart tone is difficult to find but is located and is 150. While you give her first trimester education, you tell her how much weight you expect her to gain. How much weight should this patient gain during pregnancy?

A) Less than 15 pounds (less than 7 kg)
B) 15 to 25 pounds (7 to 11.5 kg)
C) 25 to 35 pounds (11.5 to 16 kg)
D) 30 to 40 pounds (12.5 to 18 kg)

Question 7

A 35-year-old bus driver comes to your office for a prenatal visit. She is approximately 28 weeks pregnant and has had no complications. She is complaining only of heartburn and has had no fatigue, headaches, leg swelling, contractions, leakage of fluid, or bleeding. On examination her blood pressure is 142/92 and her urine shows no glucose, protein, or leukocytes. Her weight gain is appropriate, with no large recent increases. Fetal tones are 140 and her uterus measures 32 cm from the pubic bone. Looking back through her chart, you see her prenatal blood pressure was 120/70 and her blood pressures during the first 20 weeks were usually 120 to 130/70 to 80. What type of blood pressure is this?

A) Normotensive for pregnancy
B) Chronic hypertension
C) Gestational hypertension
D) Preeclampsia

Question 8

A 26-year-old stewardess comes in for a third trimester prenatal visit. She has had prenatal care since her sixth week of pregnancy. She has no complaints today and her prenatal course has been unremarkable. Today her blood pressure and weight gain are appropriate and her urine is unremarkable. You have a first-year medical student shadowing you, so you ask the student to get Doptones and measure the patient's uterus in centimeters. The student promptly reports fetal heart tones of 140, but he is having difficulty obtaining the correct measurement. He knows one end of the tape goes over the uterine fundus. From what inferior anatomic position should the tape be placed?

A) Vagina
B) Clitoris
C) Pubic symphysis
D) Umbilicus

Question 9

A 24-year-old cashier comes to your clinic for her first OB visit. She had her last period 10 weeks before, which would mean she is 12 weeks pregnant. She did a home pregnancy urine test a month ago and it was positive. She has had some fatigue and nausea, but not in the last week. She has had no cramping or bleeding. Her vital signs, head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are all unremarkable. On speculum examination her os is closed and there is a pinkish hue to the cervix. On bimanual examination the cervix is soft and the uterus is enlarged to the pelvic brim. Despite 20 minutes of trying, you cannot find heart tones. You repeat a urine pregnancy test and it is negative. A serum pregnancy test is ordered and is positive. You send the patient for a vaginal ultrasound. What is the most likely explanation for her presentation?

A) Earlier than 12 weeks
B) Fetal demise (missed abortion)
C) False pregnancy

Question 10

A 26-year-old white female comes to your clinic at 38 weeks, complaining of intermittent contractions. They last for 30 seconds and are coming every 10 minutes. Her prenatal course has so far been uneventful. You send her to labor and delivery for a labor assessment. On vaginal examination she has effaced 4 cm, but you cannot feel a presenting part. You admit her for active labor; however, you wish to assess if she is vertex (baby's head is down), so you do the Leopold's maneuver. Palpating the upper pole with your hands, you feel a firm round mass. Placing your hand along the right side of her abdomen, you feel a smooth firmness. Palpating your other hand along the left side of her abdomen, you feel irregular bumps. Above the pelvic brim you feel a firm irregular mass. While awaiting ultrasound to confirm your diagnosis, you write the pertinent orders. How is this fetus presenting?

A) Vertex
B) Breech
C) Transverse

Question 11

Jeannie is a 24-year-old pregnant woman who asks you today if her frequent urination is normal. Which of the following hormones is most likely responsible for this?

A) TSH
B) HCG
C) Oxytocin
D) Estradiol

Question 12

Which of the following is the major effect of placental hormones?

A) Insulin resistance
B) Increased tidal volume
C) Relative hypercortisolism, which may trigger labor
D) Decreased lower esophageal sphincter tone

Question 13

A young woman comes in for a routine wellness examination. You notice that her vaginal walls have deep rugae and are slightly bluish in color. She also has a thicker white discharge. What should you suspect?

A) Hypoxia
B) Varicosities
C) Pregnancy
D) Sexually transmitted infection

Question 14

Mrs. Kelly comes to you for her usual prenatal check-up. You measure the fundal height at 24 cm. What would you estimate the length of her gestation to be?

A) 20 weeks
B) 24 weeks
C) 28 weeks
D) 32 weeks

Question 15

A pregnant woman is concerned by the recent onset of a midline swelling. It is soft and nontender. What does this represent?

A) Linea nigra
B) Chadwick's sign
C) Round ligament pain
D) Diastasis recti

Question 16

A young mother presents with a pregnancy confirmed by urine HCG. Her LMP was June

A) March 27
B) April 13
C) February 20
D) February 13

Question 17

Using Naegele's rule, you estimate what day of delivery?

A) March 27
B) April 13
C) February 20
D) February 13

Question 18

A pregnant woman finally comes in for her prenatal checkup. She complains today of headache and abdominal pain of several months' duration. She appears somewhat hurried or nervous. What question would you ask next?

A) Do you have a family history of thyroid disease?
B) Have you been eating properly and taking a prenatal vitamin?
C) Do you feel safe at home?
D) How much activity have you been able to fit into your schedule?

Question 19

A woman in her 24th week of pregnancy notices she feels faint when lying down for a period. What would you suspect as a cause for this?

A) Adrenal insufficiency
B) Orthostatic hypotension
C) Supine hypotensive syndrome
D) Hypoglycemia

Question 20

Lucille is in her 24th week. You notice a new onset of high blood pressure readings. Today's value is 168/96. Her urine is normal. What do you suspect?

A) Preeclampsia
B) Chronic hypertension
C) Supine hypotensive syndrome
D) Gestational hypertension

Question 21

Which of the following is worrisome in Melissa, a woman in her 26th week of pregnancy?

A) Generalized hair loss
B) A hyperpigmented rash over the maxillary region bilaterally
C) Nosebleeds
D) Facial edema

Question 22

A woman in her third trimester complains of shortness of breath on occasion, without other symptoms. She has a normal examination. The most likely cause of this symptom is:

A) Hormonal
B) Asthma
C) Pulmonary embolus
D) Infection

Question 23

During cardiac examination you notice a new parasternal systolic murmur of 2/6 intensity. On palpation, the PMI is slightly higher than usual. What do you suspect?

A) Mammary souffle
B) Mitral stenosis
C) Mitral regurgitation
D) Aortic insufficiency

Question 24

You are examining for fetal heart tones with a fetoscope and are unable to hear any. Using a Doptone, you measure the rate as 164. Which gestational age is most likely?

A) 8 weeks
B) 14 weeks
C) 20 weeks
D) 26 weeks

Question 25

A woman in her 30th week has a cervical length estimated at 1 cm. Should you be concerned?

A) Yes; she may be at risk for preterm labor.
B) Yes; she most likely has a bicornuate uterus.
C) No; this is a normal measurement for this gestational age.
D) Yes; it likely indicates the fetus is in the breech position.

Question 26

A woman has a positive pregnancy test and comes to you with left lower quadrant pain. On bimanual examination, you feel a tender mass. Which of the following should you suspect?

A) Threatened abortion
B) Appendicitis
C) Ovarian cyst
D) Tubal pregnancy