217. A 24-year-old primigravid woman, who plans to breastfeed, decides to have a home delivery. Immediately after the birth of a 4.1-kg (9-lb) newborn, the patient experiences massive hemorrhage from extensive vaginal and cervical lacerations. She is brought to the nearest hospital in shock. Over the course of 2 hours, nine units of blood are transfused, and the patient’s blood pressure returns to a reasonable level. A hemoglobin value the next day is 7.5 g/dL, and three more units of packed red blood cells are given. The most likely late sequela to consider in this woman is which of the following?

218. A 27-year-old G4P3 at 37 weeks presents to labor and delivery with heavy vaginal bleeding and painful uterine contractions. A bedside ultrasound demonstrates a fundal placenta. The patient’s vital signs are: blood pressure 140/92 mm Hg, pulse 118 beats per minute, respiratory rate 20 breaths per minute, and temperature 37°C (98.6°F). The fetal heart rate tracing reveals tachycardia with decreased variability and intermittent late decelerations. She is taken to the OR for an emergency cesarean, and delivers a male infant with Apgar scores of 4 and 9. When the placenta is delivered, a large retroplacental clot is noted. The patient becomes hypotensive, and bleeding is noted from the wound edges and her IV catheter sites. Which of the following blood products will most quickly resolve her cause of hemorrhage?

219. A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breastfeed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. The baby latches on appropriately and begins to suckle.

In the mother, which of the following is a response to newborn suckling?

220. A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breastfeed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. The baby latches on appropriately and begins to suckle.

Which of the following aspects of her history might prevent this patient from breastfeeding?

221. A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breastfeed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. The baby latches on appropriately and begins to suckle.

The patient asks you about the pros and cons of breastfeeding. Which of the following is an accurate statement regarding breastfeeding?

222. A 30-year-old G5P3 has undergone a repeat cesarean delivery. She wants to breastfeed. Her past medical history is significant for hepatitis B infection, hypothyroidism, depression, and breast reduction. She is receiving intravenous antibiotics for endometritis. The baby latches on appropriately and begins to suckle.

The patient returns to see you in 6 weeks for a routine postpartum visit. She has been nursing her baby without any major problems, and wants to continue to do so for at least 9 months. She is ready to resume sexual activity and wants to know what her options are for contraception. She is a nonsmoker, and her only other medication is a prenatal vitamin. Which of the following methods may decrease her milk supply?

223. On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are: blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6°C (99.8°F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry shows an oxygen saturation of 88% on room air, and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?

224. A 26-year-old G1P1 is now postoperative day (POD) 6 after a low-transverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 39°C (102.2°F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with a firm, nontender uterus below the umbilicus. On pelvic examination, her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative. Which of the following statements accurately describes this patient’s condition?

225. A 24-year-old who delivered her first baby 5 weeks ago calls your office and asks to speak to you. She states that she is feeling very overwhelmed and anxious about taking care of her newborn son. She feels she cannot do anything right, and feels sad throughout the day. She tells you that she cries on most days, and is having difficulty sleeping at night. She also states she doesn’t feel like eating or doing any of her normal activities. She reports no suicidal or homicidal ideation.

Which of the following is the most likely diagnosis?

226. A 24-year-old who delivered her first baby 5 weeks ago calls your office and asks to speak to you. She states that she is feeling very overwhelmed and anxious about taking care of her newborn son. She feels she cannot do anything right, and feels sad throughout the day. She tells you that she cries on most days, and is having difficulty sleeping at night. She also states she doesn’t feel like eating or doing any of her normal activities. She reports no suicidal or homicidal ideation.

Which of the following accurately describes this patient’s condition?

227. A 35-year-old G3P3 presents to your office 3 weeks after an uncomplicated vaginal delivery. She has been successfully breastfeeding. She reports chills and a fever up to 38.3°C (101°F) at home. She states that she feels like she has flu, but has not had any sick contacts. She has no medical problems, prior surgeries, or allergies to medications. On examination, she has a temperature of 38°C (100.4°F) and generally appears in no distress. Head, ear, throat, lung, cardiac, abdominal, and pelvic examinations are all normal. A triangular area of erythema and tenderness is noted in the upper outer quadrant of the left breast. No masses or axillary lymphadenopathy are noted. Which of the following is the best option for treatment of this patient?

228. A 22-year-old G1 at 34 weeks is tested for tuberculosis because her father, with whom she lives, was recently diagnosed with tuberculosis. Her skin test is positive and her chest x-ray demonstrates a granuloma in the upper left lobe. Which of the following is true concerning infants born to mothers with active tuberculosis?

229. A 23-year-old G2P1 develops chorioamnionitis during labor and is started on ampicillin and gentamicin. She requires a cesarean delivery for arrest of active phase labor. What is the most optimal way to reduce her chance of developing postoperative endometritis?

230. A 21-year-old G2P2 calls her physician 7 days postpartum because she is concerned that she is still experiencing vaginal bleeding. She describes the bleeding as light pink to bright red, and less heavy than the first few days postdelivery. She reports no fever or pain. On examination, she is afebrile and has an appropriately sized, nontender uterus. The vagina contains about 10 cc of old, dark blood. The cervix is closed. Which of the following is the most appropriate treatment?

231. A 28-year-old G2P2 presents to the hospital 2 weeks after vaginal delivery with a chief complaint of sudden onset heavy vaginal bleeding that soaks a sanitary napkin every hour. Her pregnancy was complicated by preterm labor, and she delivered precipitously at 26 weeks’ gestation. Her pulse is 89 beats per minute, blood pressure 120/76 mm Hg, and temperature 37.1°C (98.9°F). Her abdomen is nontender and her fundus is located above the symphysis pubis. On physical examination, you note active bleeding from the uterus, and you estimate a blood loss of 500 cc during the examination. Her uterus is about 12 to 14 weeks size and nontender. Her cervix is closed. An ultrasound reveals an irregularly thickened endometrial stripe. Her hemoglobin is 10.9 g/dL, unchanged from the one at her vaginal delivery. β-HCG is negative. Which of the following is the most appropriate treatment for the cause of her vaginal bleeding?

232. A 22-year-old G1P0 has just undergone a spontaneous vaginal delivery. As the placenta is being delivered, a red fleshy mass is noted to be protruding out from behind the placenta. Which of the following is the best next step in management of this patient?

233. Three days ago you delivered a 40-year-old G1P1 by cesarean following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse calls you to come to see the patient on the postpartum floor because she has a fever of 38.8°C (102°F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breastfeed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted.

Which of the following is the most likely diagnosis?

234. Three days ago you delivered a 40-year-old G1P1 by cesarean following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse calls you to come to see the patient on the postpartum floor because she has a fever of 38.8°C (102°F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breastfeed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted.

Which of the following is the most appropriate antibiotic to treat this patient with initially?

235. Three days ago you delivered a 40-year-old G1P1 by cesarean following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse calls you to come to see the patient on the postpartum floor because she has a fever of 38.8°C (102°F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breastfeed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted.

After 48 hours of treatment, the patient remains febrile. What is the most appropriate next step in management?

236. A 22-year-old G1P1 is brought to the emergency department by EMS after having a seizure at home. She is 2 weeks’ postpartum after an uncomplicated spontaneous vaginal delivery. She has no medical problems, and her pregnancy, labor, and immediate postpartum period were unremarkable. On arrival, her vitals were: blood pressure 165/95 mm HG, pulse 82 beats per minute, respiratory rate 20 breaths per minute. What is the most appropriate next step in management?

237. You are doing postpartum rounds on a 23-year-old G1P1 who is postpartum day 2 after an uncomplicated vaginal delivery. As you walk into the room, you note that she is crying. She states she can’t seem to help it. She says she does not feel sad or anxious. She has not been sleeping well because she is getting up every 2 to 3 hours to breastfeed her new baby. Her past medical history is unremarkable. Which of the following is the most appropriate treatment recommendation?

238. A 20-year-old G1P1 is postpartum day 2 after an uncomplicated vaginal delivery of a 6-lb 10-oz baby boy. She is trying to decide whether to have you perform a circumcision on her newborn. The boy is in the well-baby nursery and is doing very well.

In counseling this patient, you tell her which of the following recommendations from the American Pediatric Association?

239. A 20-year-old G1P1 is postpartum day 2 after an uncomplicated vaginal delivery of a 6-lb 10-oz baby boy. She is trying to decide whether to have you perform a circumcision on her newborn. The boy is in the well-baby nursery and is doing very well.

The parents ask if you will use analgesia during the circumcision. What do you tell them regarding the recommendations for administering pain medicine for circumcisions?

240. A 33-year-old G1P0 was induced for being postterm at 42½ weeks’ gestation. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical examination: a small amount of cartilage in the earlobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae. Based on this physical examination, what is the approximate gestational age of this male infant?

241. A 40-year-old G4P5 at 39 weeks’ gestation has progressed rapidly in labor with a reassuring fetal heart rate pattern. She has had an uncomplicated pregnancy with normal prenatal laboratory tests, including an amniocentesis for advanced maternal age. The patient begins the second stage of labor, and after 15 minutes of pushing, starts to demonstrate recurrent variable heart rate accelerations. You suspect that she may have a fetus with a nuchal cord. You expediently deliver the baby by low-outlet forceps, and hand the baby over to the neonatologists called to attend the delivery. As soon as the baby is handed off to the pediatric team, it lets out a strong spontaneous cry. The infant is pink with slightly blue extremities that are actively moving and kicking. The heart rate is noted to be 110 beats per minute on auscultation. What Apgar score should the pediatricians assign to this baby at 1 minute of life?

242. A 32-year-old G2P1 at 41 weeks’ gestation is undergoing an induction of labor for oligohydramnios. During the course of her labor, the fetal heart rate tracing demonstrates recurrent variable decelerations that do not respond to oxygen, intravenous fluid, or amnioinfusion. The patient’s cervix is dilated to 4 cm. A low-transverse cesarean delivery is performed for a nonreassuring fetal heart tracing remote from delivery. After delivery of the fetus, you send a cord gas, which comes back with the following arterial blood values: pH 7.29, Pco2 50 mm Hg, and Po2 20 mm Hg. What condition does the cord blood gas indicate?

243. You are asked to assist in the well-born nursery with neonatal care. Which of the following is a part of routine care in a healthy infant?

244. A 35-year-old G2P2 presents for her routine postpartum visit. Her pregnancy was complicated by gestational diabetes, which was diagnosed in the second trimester during routine screening. She has no other medical problems, and she has no family history of diabetes. She gained 25 pounds during her pregnancy, and her gestational diabetes was managed with diet modification.

She asks whether she is at an increased risk for diabetes later in life. How should you counsel her?

245. A 35-year-old G2P2 presents for her routine postpartum visit. Her pregnancy was complicated by gestational diabetes, which was diagnosed in the second trimester during routine screening. She has no other medical problems, and she has no family history of diabetes. She gained 25 pounds during her pregnancy, and her gestational diabetes was managed with diet modification.

The patient asks if the fact that she had gestational diabetes might have any long-term effects on her baby. How should you counsel her?

246. A 35-year-old G2P2 presents for her routine postpartum visit. Her pregnancy was complicated by gestational diabetes, which was diagnosed in the second trimester during routine screening. She has no other medical problems, and she has no family history of diabetes. She gained 25 pounds during her pregnancy, and her gestational diabetes was managed with diet modification.

How should this patient be managed postpartum?

247. A 30-year-old G3P3, who is 8 weeks’ postpartum and regularly breastfeeding calls you and is very concerned because she is having pain with intercourse secondary to vaginal dryness. Which of the following should you recommend to help her with this problem?

248. A 34-year-old G1P1 comes to see you 6 weeks after an uncomplicated vaginal delivery for a routine postpartum examination. She reports no problems, and has been breastfeeding her newborn without any difficulties since leaving the hospital. During the bimanual examination, you note that her uterus is irregular, firm, nontender, and about a 15-week size. Which of the following is the most likely etiology for this enlarged uterus?

249. A 39-year-old G3P3 comes to see you on day 5 after a repeat cesarean delivery. During the surgery she received two units of packed red blood cells for a hemorrhage related to uterine atony. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. She is concerned because her incision has become very red and tender, and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 38.8°C (102°F). Her vital signs are: temperature 37.8°C (100.1°F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Physical examination shows erythema around the incision, and a 1-cm defect at the left corner of the skin incision, which is draining a small amount of purulent liquid. There is tenderness along the wound edges.

Which of the following is the best next step in the management of this patient?

250. A 39-year-old G3P3 comes to see you on day 5 after a repeat cesarean delivery. During the surgery she received two units of packed red blood cells for a hemorrhage related to uterine atony. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. She is concerned because her incision has become very red and tender, and pus started draining from a small opening in the incision this morning. She has been experiencing general malaise and reports a fever of 38.8°C (102°F). Her vital signs are: temperature 37.8°C (100.1°F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Physical examination shows erythema around the incision, and a 1-cm defect at the left corner of the skin incision, which is draining a small amount of purulent liquid. There is tenderness along the wound edges.

Which of the following is her greatest risk factor for her complication?