72. Pelvic examination is performed in a 34-year-old P0101 at 34 weeks’ gestation who is in labor. The patient is noted to be 6 cm dilated, and completely effaced with the fetal nose and mouth palpable. The chin is pointing toward the maternal left hip. This is an example of which of the following?

73. You are counseling a 36-year-old obese, Hispanic G2P1 at 36 weeks’ gestation about route of delivery. During her first pregnancy, she was induced at 41 weeks’ gestation for mild preeclampsia, and delivered by cesarean as a result of fetal distress during her induction. The patient would like to know if she can have a trial of labor after cesarean (TOLAC) with this pregnancy. Which of the following is the best response to this patient?

74. The patient wants to know about the probability of success if she chooses to undergo TOLAC. What can you tell her about factors that impact the probability of success in TOLAC?

75. The patient has still not gone into spontaneous labor at 41 weeks’ gestation. You see her in clinic and her blood pressure is 150/90 mmHg and she has +3 proteinuria on urine dipstick. You send her to labor and delivery for further evaluation, and her blood pressure remains elevated, consistent with a diagnosis of preeclampsia. You examine her cervix and find that it is closed and thick. She asks whether she can undergo induction of labor at this point. What should you tell her about induction of labor?

76. A 32-year-old poorly controlled diabetic G2P1 is undergoing amniocentesis at 38 weeks for fetal lung maturity prior to having a repeat cesarean delivery. Which of the following laboratory tests results on the amniotic fluid would best indicate that the fetal lungs are mature?

77. A 26-year-old G1P0 patient at 34 weeks’ gestation is being evaluated with Doppler ultrasound studies of the fetal umbilical arteries. The patient is a healthy smoker. Her fetus has shown evidence of intrauterine growth restriction (IUGR) on previous ultrasound examinations. The Doppler studies currently show that the systolic to diastolic ratio (S/D) in the umbilical arteries is much higher than it was on her last ultrasound 3 weeks ago, and there is now reverse diastolic flow. Which of the following is correct information to share with the patient?

78. A 17-year-old primipara presents to your office at 41 weeks. Her pregnancy has been uncomplicated. Because her cervix is unfavorable for induction of labor, she is being followed with biophysical profile (BPP) testing. Which of the following is correct information to share with the patient regarding BPPs?

79. A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time?

80. A patient presents for her first OB visit after having a positive home pregnancy test. She reports her last menstrual period was about 8 weeks ago, but she is not entirely certain because she has a long history of irregular menses. Her urine pregnancy test in your office is positive. Which of the following is the most accurate way to date this patient’s pregnancy?

81. A healthy 26-year-old G1P0 presents for her first OB visit at 10 weeks’ gestation. She has no significant personal or family medical history.

When should she have her screening test for gestational diabetes?

82. A healthy 26-year-old G1P0 presents for her first OB visit at 10 weeks’ gestation. She has no significant personal or family medical history.

She fails her 1-hour glucose challenge test at 26 weeks. What is the next best step in management?

83. A healthy 31-year-old G3P2002 patient presents at 34 weeks for a routine OB visit. She has had an uneventful pregnancy to date. Her baseline blood pressures were 100 mm Hg to 110/60 mm Hg to 70 mm Hg in the first trimester, and she has gained a total of 20 lb so far. During the visit, the patient complains of swelling in both her feet and ankles that sometimes causes her feet to ache at the end of the day. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75 mm Hg. She has no other symptoms or complaints. On physical examination, there is pitting edema of both her feet and ankles extending to the lower one-half of her legs. There is no calf tenderness. Which of the following is the most appropriate response to the patient’s concern?

84. A 28-year-old G1P0 presents to your office at 24 weeks’ gestation for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occurring with movement and exercise. She reports no change in urinary or bowel habits, and no fever or chills. Sitting down and putting her feet up helps alleviate the discomfort. As her obstetrician, what should you tell her is the most likely etiology of this pain?

85. A 19-year-old G1P0 presents to her obstetrician’s office for a routine OB visit at 32 weeks’ gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompliant with diet and insulin therapy. She has had two prior normal ultrasound examinations at 20 and 28 weeks’ gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm. Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age?

86. A 43-year-old G1P0 who conceived via in vitro fertilization comes into the office for her routine OB visit at 38 weeks. She reports good fetal movement and reports no leakage of fluid, vaginal bleeding, or regular uterine contractions. She reports that sometimes she feels crampy at the end of the day when she gets home from work, but this discomfort is alleviated with getting off her feet. The fundal height measurement is 36 cm; it measured 37 cm the week before. Her cervical examination is 2 cm dilated and the fetal head is engaged. Which of the following is the most appropriate next step in the management of this patient?

87. A pregnant woman who is 7 weeks from her LMP comes in to the office for her first prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The patient therefore is very anxious about the well-being of this pregnancy. Which of the following modalities will allow you to best document fetal cardiac activity?

88. A 30-year-old G2P1001 presents to your office at 37 weeks for her routine OB visit. Her first pregnancy resulted in a vaginal delivery of a 9-lb 8-oz baby boy after 30 minutes of pushing. On doing Leopold maneuvers during this office visit, you determine that the fetus is breech. Vaginal examination demonstrates that the cervix is 50% effaced and 2-cm dilated. The presenting breech is high out of the pelvis. The estimated fetal weight is about 7 lb. The patient reports no contractions. You send the patient for an ultrasound, which confirms a fetus with a double footling breech presentation. There is a normal amount of amniotic fluid present, and the head is hyperextended in the “stargazer” position. Which of the following is the best next step in the management of this patient?

89. A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40 weeks by a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement and no contractions. She has been doing kick counts for the past several days, and reports that the baby moves at least ten times in 2 hours. On physical examination, her cervix is firm, posterior, 50% effaced, and 1-cm dilated, and the vertex is at a-1 station.

As her obstetrician, which of the following should you recommend to the patient as the best next step in management?

90. A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40 weeks by a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement and no contractions. She has been doing kick counts for the past several days, and reports that the baby moves at least ten times in 2 hours. On physical examination, her cervix is firm, posterior, 50% effaced, and 1-cm dilated, and the vertex is at a-1 station.

The patient presents in 1 week for a follow-up visit. She is now 41 weeks’ gestation. She reports that the baby is still passing the fetal kick count assessment, and she has been having intermittent contractions for several days. On physical examination, her cervix is 3 cm dilated, 70% effaced, anterior, soft, and the vertex is at 0 station. Now what is the next best step in management?

91. A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40 weeks by a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement and no contractions. She has been doing kick counts for the past several days, and reports that the baby moves at least ten times in 2 hours. On physical examination, her cervix is firm, posterior, 50% effaced, and 1-cm dilated, and the vertex is at a-1 station.

What would the next best step in management be if this patient were 41 weeks with an unfavorable cervix and oligohydramnios found on

ultrasound?

92. A healthy 30-year-old P1001 at 24 weeks’ gestation presents for a routine OB visit. She has no medical problems, and her pregnancy has been uncomplicated. Her last pregnancy was uncomplicated as well. However, she tells you that with her last pregnancy, her obstetrician performed an ultrasound at every visit to reassure her that “everything was alright.” She requests that you also perform an ultrasound at every visit to provide her reassurance that the pregnancy is progressing normally. How should you counsel her regarding the safety of ultrasound during pregnancy?

93. A 27-year-old G3P2002, who is 34 weeks’ gestational age, calls the on-call obstetrician on a Saturday night at 10:00 pm reporting decreased fetal movement. She says that the previous day her baby moved only once per hour. For the past 6 hours she has felt no movement. She is healthy, has had regular prenatal care, and reports no complications so far during the pregnancy. Which of the following is the best advice for the on-call physician to give the patient?

94. Your patient reports decreased fetal movement at term. You recommend a modified BPP test. NST in your office was reactive. The next part of the modified BPP is which of the following?

95. You are seeing a patient in the hospital for decreased fetal movement at 36 weeks’ gestation. She is healthy and has had no prenatal complications. You order a BPP. The patient scores an 8 on the test. Two points were deducted for lack of fetal breathing movements. How should you counsel the patient regarding the results of the BPP?

96. An 18-year-old G2P1001 presents for her first OB visit at 10 weeks. She reports that the first day of her last menstrual period was May 7. What is this patient’s estimated date of delivery?

97. A 36-year-old G1P0 presents to your office for her first prenatal visit. By her last menstrual period she is 11 weeks’ pregnant. She has no medical problems. On physical examination, her uterus is palpable midway between the pubic symphysis and the umbilicus. No fetal heart tones are audible with the Doppler stethoscope. Which of the following is the best next step in the management of this patient?

98. A healthy 30-year-old G2P1001 presents to her obstetrician’s office at 34 weeks for a routine prenatal visit. She has a history of a low transverse cesarean delivery performed secondary to fetal malpresentation (footling breech). Her current pregnancy has been uncomplicated. She tells her physician that she would like to undergo a trial of labor during this pregnancy. However, the patient is interested in permanent sterilization and wonders if it would be better to undergo another scheduled cesarean so she can have a bilateral tubal ligation performed at the same time. How should the physician counsel this patient?

99. A 16-year-old primigravida presents to your office at 38 weeks’ gestation. Her first trimester blood pressure was 100/72 mm Hg. On the day of presentation it was 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine. She has significant swelling of her face and extremities. She reports no contractions. Her cervix is closed and thick. The baby is breech by bedside ultrasonography. She reports the baby’s movements have decreased in the past 24 hours. Which of the following is the best next step in the management of this patient?

100. While you are on call at the hospital covering labor and delivery, a 32-year-old G3P2002, at 35 weeks’ gestation, presents with a chief complaint of lower back pain. You take her history, and learn that she had been lifting some heavy boxes while preparing the baby’s nursery. The patient’s pregnancy has been complicated by diet-controlled gestational diabetes. She reports no uterine contractions, rupture of membranes, vaginal bleeding, dysuria, fever, chills, nausea, or emesis. She states that the baby has been moving normally. She is afebrile and her blood pressure is normal. On physical examination, you note that she is obese. Her abdomen is soft and nontender, with no palpable contractions or uterine tenderness. No costovertebral angle tenderness can be elicited. On pelvic examination her cervix is closed and thick. The fetal heart tracing is reactive, and there are rare, irregular uterine contractions demonstrated on the tocometer. The patient’s urinalysis shows trace glucose, but is otherwise negative. The patient’s most likely diagnosis is which of the following?