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Thursday, January 15,2015

12:22AM

Exam Sect1on : Item 1 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remammg:
2 hr 49 min 39 sec

1. A 12-year-old girl is brought to the physician because of a 1-year history of progressive facial hair growth and acne. The mother reports that her daughter has grown 4 inches during the
past 4 months. Breast development is Tanner stage 1, and axillary and pubic hair development are Tanner stage 3. Physical examination shows dark hair over the upper lip, cheeks, and
chin. There is acne vulgaris over the cheeks. Pelvic examination shows a 2-cm vaginal canal, significant clitoromegaly, posterior labioscrotal fusion, and no cervix or palpable uterus.
Abdominal ultrasonography shows bilateral gonads without follicles; there is no uterus. Chromosomal analysis is most likely to show which of the following karyotypes?
Q A) ~

8 ) 46,XX
@ C) 46,XY
Q D) ~

Q E) ~

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NBME 2 OBGYN Page 1

Thursday, January 15,2015

12:22AM

Exam Section : Item 2 of 50

Nat1onal Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 49 min 23 sec

2. A 27-year-old nulligravid woman comes to the physician because of dyspareunia and dysmenorrhea for 2 years. Menses occur at regular 28-day intervals. Pelvic
examination shows nodularity over the uterosacral area. The uterus is retroverted . Both adnexa are normal-sized but tender. Which of the following is the most
appropriate next step in diagnosis?

0
0
0
0

A) Measurement of serum CA 125 concentration


B) Measurement of serum a-fetoprotein concentration
C) CT scan of the abdomen
D) MRI of the pelvis

@ E) Laparoscopy

1/15/201512:22 AM - Screen dipping

NBME 2 OBGYN Page 2

Thursday, January 15,2015

12:22AM

Exam Section : Item 3 of 50


1!'.1 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 49 min 17 sec

3. A 57-year-old woman , gravida 2, para 2, comes to the physician because of pelvic pressure and a feeling of a mass in the vagina for 2 months. These symptoms are
worse while standing for long periods of time and are relieved by lying down. She had a vaginal hysterectomy 10 years ago. She has no urinary tract symptoms and no
difficulty with her bowel movements. Examination shows no anterior vag inal relaxation. Valsalva maneuver produces a bulging posterior vaginal mass that has its origin
high in the vaginal vau lt. Which of the following is the most likely diagnosis?

0 A) Cervical tumor
0 B) Cystocele
@ C) Enterocele

0 D) Ureterocele

0 E) Urge incontinence
0 F) Urinary tract infection
0 G) Uterine prolapse

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NBME 2 OBGYN Page 3

4 Dates
Thursday, January 15, 2015

12:22 AM

Exam Section: Item 4 of 50


~Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 49 min 12 sec

4. A 22-year-old woman, gravida 3, para 1, aborta 1, at 33 weeks' gestation comes to the physician for a routine prenatal visit. Pregnancy has been uncomplicated, and she
has received prenatal care since 7 weeks' gestation . Ultrasonography at 24 weeks' gestation showed no abnormalities. She has type 1 diabetes mellitus, and her
postprandial serum glucose concentration was 95 mg/dl at 28 weeks' gestation. Her blood pressure is 110/72 mm Hg. Fundal height is 38 em. Her blood group is A,
Rh-positive. Which of the following is the most likely diagnosis?

-::QJ
0
0
0

A) Error in gestational age


B) Multiple gestation
C) Pelvic tumor
D) Polyhydramnios

)fJ E) Normal pregnancy variation of fundal height

1/15/2015 12:22 AM- Screen Clipping

Likely D -7 diabetes type 1 -7 polyhydramnios


Any diabetes is associated with polyhdramnios, and polydhydram nios can cause increased f undal
height

NBME 2 OBGYN Page 4

Thursday, January 15,2015

12:22AM

Exam Section : Item 5 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 49 min 8 sec

5. A healthy 24-year-old primigravid African American woman at 11 weeks' gestation comes to the physician for a routine prenatal visit. Her only medication is prenatal
vitamins. Her blood pressure is 120/70 mm Hg. Examination shows no peripheral edema. The fetal heart rate is 150/min. At her first prenatal visit 4 weeks ago,
laboratory studies showed:
Hemoglobin
Mean corpuscular hemoglobin
Mean corpuscular volume

10.2g/dl
20 pg/cell

Leukocyte count

10,900/mm3
140,000/mm3

Platelet count
Hemoglobin electrophoresis
Hemoglobin A

72 J..lm 3

95%

Urinalysis today shows no glucose, protein, or ketones. Which of the following is the most likely cause of these laboratory findings?

0 A) Folic acid deficiency


@ B) Iron deficiency

0 C) Physiologic dilution of pregnancy


0 D) Sickle cell disease
0 E) Vitamin 8 12 (cobalamin) deficiency

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NBME 2 OBGYN Page 5

6 arrest descent
Thursday, January 15,2015

12:23AM

Exam Sect1on : Item 6 of 50


L'!ll Mark

Nat1onal Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 49 min 3 sec

6. A 28-year-old woman , gravida 2, para 1, comes to the physician for her first prenatal visit. Her last menstrual period was 10 weeks ago. Her first child, a 4540-g (10-lb)

.,)<- male newborn, was born by cesarean delivery because of an arrest of descent. During this pregnancy, she is at increased risk for which of the following?
@ A) Abruptio placentae

0
0
0
0

B) Gestational diabetes
C) Polyhydramnios
D) Preeclampsia
E) Premature rupture of the membranes

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NOT A or E.

Big baby, gestational diabetes?

NBME 2 OBGYN Page 6

7 vulvar carcinoma
Thursday, January 15,2015

12:23AM

Exam Section : Item 7 of 50


~ Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 48 min 58 sec

'

7. A previously healthy 57-year-old woman comes to the physician because of a 2-month history of vulvar itching. She is otherwise asymptomatic and takes no
medications. Menopause occurred 7 years ago. She has not been sexually active for 10 years. Examination shows a 1 x 1:.--2-cm ulcerated lesion on the inner right
labium majus surrounded by mild erythema; no other lesions are noted. There is no inguinal adenopathy. Which of the following is the most likely diagnosis?

0
0
0
0

A) Herpes simplex
B) Hypertrophic vulvar dystrophy
C) Lichen sclerosus
D) Primary syphilis

@ E) Vulvar carcinoma

0 F) War: condylomata acuminata

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NBME 2 OBGYN Page 7

Thursday, January 15,2015

12:23AM

Exam Section : Item 8 of 50


~ Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 48 min 53 sec

'

8. A previously healthy 22-year-old woman comes to the physician because of a bump on her vulva for 1 week. She has been sexually active with one partner for 2 years.
She uses an oral contraceptive. Examination shows multiple 0.25-cm raised, crusty papules on the posterior fourchette. A Pap smear shows low-grade squamous
intraepithelial lesions. Which of the following is the most likely diagnosis?

0 A) Chancroid
0 B) Chlamydia trachomatis infection
@ C) Condylomata acuminata

D) Herpes genitalis

0 E) Lymphogranuloma venereum
0 F) Molluscum contagiosum

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NBME 2 OBGYN Page 8

Thursday, January 15, 2015

12:23AM

Exam Sect1on : Item 9 of 50


Mark

Nat1onal Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

Time Remainmg:
2 hr 48 min 49 sec

9. A previously healthy 57-year-old woman comes to the physician because of a 6-month history of urinary urgency and loss of urine that requires the use of an absorbent
pad. She rarely leaves her house because she is afraid of having loss of urine in public. She typically awakens once each night to void. She has not had fever, pain with
urination, or blood in her urine. She says her urine stream is normal. Her temperature is 3JOC (98.6F). Physical examination, including pelvic examination, shows no
abnormalities. Urinalysis shows no abnormalities. Pelvic ultrasonography shows a 3-cm, anterior, uterine mass consistent with a benign leiomyoma uteri. Wh ich of the
following is the most likely cause of this patient's incontinence?
@ A) Detrusor instability

0
0
0
0

B) Leiomyoma uteri
C) Urethral hypermobility
D) Urinary retention with overflow
E) Urinary tract infection

1/15/2015 12:23 AM Screen Clipping

NBME 2 OBGYN Page 9

Thursday, January 15,2015

12:23AM

Exam Section : Item 10 of 50


1!'.1 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 48 min 44 sec

10. For the past 4 months, a perimenopausal 48-year-old woman has had a spontaneous intermittent serosanguineous discharge from the nipple of the left breast. No
mass is palpable. Screening mammography is within normal limits. Which of the following is the most likely cause of this problem?

0 A) Ductal ectasia
0 B) Fibrocystic changes of the breast
0 C) Intraductal carcinoma
@ D) Intraductal papilloma

0 E) Recurrent periareolar duct infection

1/15/201512:23 AM Screen Gipping

NBME 2 OBGYN Page 10

Thursday, January 15,2015

12:23AM

Exam Sect1on: Item 11 of 50

Nat1onal Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remammg:
2 hr 48 min 40 sec

11. A 32-year-old woman, gravida 3, para 2, delivers a 4111-g (9-lb 1-oz) newborn at term following a 2-hour second stage of labor assisted by a medial episiotomy. The
placenta delivers 12 minutes later using gentle umbilical cord traction. Following delivery of the placenta, a firm pale mass is noted in the lower vagina ; there is
moderate vaginal bleeding_The patient develops shortness of breath. Her pulse is 60/min, and blood pressure is 60/40 mm Hg. On abdominal examination, the uterus
cannot be palpated. Treatment with intravenous saline does not improve her symptoms. Which of the following is the most likely diagnosis?

0 A) Placenta accreta
0 B) Retained placental fragments
0 C) Uterine atony
@ D) Uterine inversion

0 E) Uterine rupture

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NBME 2 OBGYN Page 11

12 USPTF
Thursday, January 15,2015

12:23AM

Exam Section : Item 12 of 50


Mark

Nat1onal Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 48 min 35 sec

The response options for the next 2 items are the same. Select one answer for each item in the set.
For each patient, select the most appropriate screening test.

0 A) ECG

B) Mammography

0 C) Measurement of serum CA 125 concentration


@ D) Measurement of serum cholesterol concentration

0 E) Measurement of serum follicle-stimulating hormone concentration

0
0
0
0
0

F) Test of the stool for occult blood


G) Testing for Chlamydia trachomatis
H) Thyroid function studies
I) Ultrasonography of the pelvis
J) X-ray of the chest

12. A 30-year-old woman comes to the physician for a routine examination. Her last office visit was 5 years ago. Her mother had breast cancer at the age of 58 years. Her
father died of a myocardial infarction at the age of 39 years. Her 36-year-old brother has type 2 diabetes mellitus. She has smoked one pack of cigarettes daily for 6
years. She uses an oral contraceptive. She is 157 em (5 ft 2 in) tall and weighs 95 kg (210 lb); BMI is 38 kgf m2

1/15/201512:23 AM- Screen dipping

Women 20-45 at Increased Risk for CHD


From <http ://www. usp reven tiveservicestaskforce.orn/u spstf/u spschol.h tm>

NBME 2 OBGYN Page 12

Thursday, January 15,2015

12:23AM

Exam Section: Item 13 of 50


1!2 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 48 min 30 sec

For each patient, select the most appropriate screening test.

0
0
0
0
0

A) ECG
B) Mammography

0 F) Test of the stool for occult blood


@ G) Testing for Chlamydia trachomatis

C) Measurement of serum CA 125 concentration

0
0
0

D) Measurement of serum cholesterol concentration


E) Measurement of serum follicle-stimulating hormone concentration

H) Thyroid function studies


I) Ultrasonography of the pelvis
J) X-ray of the chest

13. A healthy 16-year-old girl comes to the physician because of painful menses for 3 years. Menarche was at the age of 12 years. Nonsteroidal anti-inflammatory drugs
have only partially relieved the pain. She is sexually active and has had one male partner; they occasionally use condoms for contraception. She does not smoke
cigarettes. Pelvic examination shows normal findings. Oral contraceptive therapy is suggested.

1/15/201512:23 AM Screen dipping

NBME 2 OBGYN Page 13

Thursday, January 15,2015

12:23AM

Exam Sect1on : Item 14 of 50


Mark

Nat1onal Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

Time Remammg:
2 hr 48 min 26 sec

14. A 32-year-old primigravid woman at 14 weeks' gestation comes to the physician because of fever, lower pelvic pressure, and vaginal spotting for 7 days. Three years
ago, she underwent two loop electrosurgical excisions of the cervical transformation zone for carcinoma in situ. Pelvic examination shows a closed cervix that is flush
against the upper vagina and measures 2 em in diameter. The uterus is consistent in size with a 14-week gestation. Pelvic ultrasonography confirms uterine size and
shows a funneled lower uterine segment; the internal cervical os measures 2 em. Which of the following is the most likely cause of this patient's vaginal bleeding?

0 A) Abruptio placentae
0 B) Cervical cancer
@ C) Cervical incompetence

0 D) Incomplete abortion
0 E) Subchorionic hemorrhage

1/15/201512:23 AM Screen Oipping

NBME 2 OBGYN Page 14

Thursday, January 15,2015

12:23AM

Exam Section : Item 15 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 48 min 22 sec

15. A 16-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She is otherwise healthy. She is 175 em (5 ft 9 in) tall and
weighs 61 kg (135 lb). Breast development is Tanner stage 3; there is no axillary or pubic hair. Pelvic examination shows a vagina that is 2 em in length. Pelvic
ultrasonography shows no uterus. Which of the following is the most likely diagnosis?

0 A) Adrenal insufficiency
@ B) Androgen insensitivity syndrome

0 C) Imperforate hymen
0 D) Paramesonephric (mOIIerian) duct agenesis
0 E) Premature ovarian failure

1/15/201512:23 AM- Screen Oipping

NBME 2 OBGYN Page 15

Thursday, January 15,2015

12:23AM

Exam Section : Item 16 of 50


~ Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 48 min 17 sec

'

16. An 18-year-old primigravid woman at 10 weeks' gestation comes to the physician for a follow-up examination. At her first prenatal visit 2 weeks ago, serum HIV antibody
testing was positive. On examination today, the lungs are clear to auscultation and percussion. There is no axillary or cervical lymphadenopathy. A PPD skin test shows
9 mm of induration at 48 hours. Which of the following is the most appropriate next step in management?

0 A) Second PPD skin test in 2 months


0 B) Second PPD skin test after delivery

C) Culture of sputum for acid-fast bacilli

@ D) X-ray of the chest

0 E) Spiral CT scan of the chest

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NBME 2 OBGYN Page 16

Thursday, January 15,2015

12:23AM

Exam Section : Item 17 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 48 min 13 sec

'

17. A 15-year-old girl is brought to the emergency department because of nausea, vomiting, and lower abdominal pain for 4 days. Her last menstrual period was 9 days
ago. She is sexually active and does not use contraception. Her temperature is 39.7"C (103.5F), pulse is 105/min, and blood pressure is 110/75 mm Hg. Physical
examination shows bilateral lower abdominal tenderness and peritoneal signs. Pelvic examination shows copious yellow cervical discharge and exquisite uterine
tenderness. Which of the following is the most appropriate next step in management?
@ A) Admission to the hospital for intravenous antibiotic therapy

0
0
0
0
0

B) Admission to the hospital for laparoscopy


C) Admission to the hospital for laparotomy
D) CT scan of the pelvis
E) Discharge with analgesic therapy
F) Discharge with oral antibiotic therapy only

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NBME 2 OBGYN Page 17

0
0
0
0
0

G) Discharge with oral and intramuscular antibiotic therapy


H) Limited-stay observation and evaluation
I) MRI of the pelvis
J) Uterine evacuation in the emergency department
K) Uterine evacuation in the operating room

18 next step
Thursday, January 15, 2015

12:24 AM

-------------------------------------------------------------------------------------------------------------------------------------

Exam Section : Item 18 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 48 min 8 sec

18. A 24-year-old primigravid woman at 28 weeks' gestation is brought to the emergency department 4 hours after she felt a sudden gush of fluid from her vagina. She is
concerned that her membranes have ruptured. Her pregnancy had been uncomplicated, and she has had good fetal movement and no contractions. She has no history
of medical or gynecologic illness or abnormal Pap smears. Her temperature is 36.9C (98.5F), pulse is 64/min, and blood pressure is 110/60 mm Hg. The fundal height
is 28 em. The fetus is in a breech presentation. External fetal monitoring shows a fetal heart rate of 150/min with moderate variability. There are no uterine contractions.
The uterus is nontender to palpation. Sterile speculum examination shows pooling of fluid in the vagina and a closed cervix. Nitrazine testing of the fluid is positive, and
ferning is seen under the microscope. Pelvic ultrasonography shows an amniotic fluid index of 5 em (N=8-24). After administration of intramuscular corticosteroids and
intravenous antibiotics, which of the following is the most appropriate next step in management?

0 A) Second administration of corticosteroids in 24 hours


_j). B) Intravenous administration of oxytocin

0 C) External cephalic version


0 D) Amniocentesis
~ E) Immediate cesarean delivery/ '

1/15/2015 12:24 AM -Screen Clipping

A) Betamethasone is given a s two shots, 24 hours apart. {12mg given intramuscularly 24 hours
apart)
NOT BORE

NBME 2 OBGYN Page 18

19 Pulmonary hypoplasia
Thursday, January 15,2015

12:24AM

Exam Section : Item 19 of 50


1!2 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 48 min 3 sec

19. A 27-year-old primigravid woman at 30 weeks' gestation delivers a 1530-g (3-lb 6-oz) newborn. Pregnancy was complicated by premature rupture of the membranes at
25 weeks' gestation; observation prior to spontaneous labor showed little to absent amniotic fluid. Apgar scores are 3 and 1 at 1 and 5 minutes, respectively. Which of
the following is the most likely explanation for the neonatal condition?

0
0
0
0
0

A) Anemia
B) Down syndrome
C) Fetal growth restriction
D) Gonadal dysgenesis 45,X (Turner syndrome)

E) Hydrops
@ F) Pulmonary hypoplasia

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Little amnioticfluid -7 pulmonary hypoplasia.


Hydrops fetal is is a condition in the fetus characterized by an accumulation of fluid, or edema, in at least two fetal compartments.

NBME 2 OBGYN Page 19

Thursday, January 15,2015

12:24AM

Exam Section : Item 20 of 50


Mark

Nat1onal Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 47 min 59 sec

20. A 47-year-old primigravid woman at 10 weeks' gestation comes to the physician for a routine prenatal visit. She conceived following oocyte donation from her
32-year-old sister. Menopause was 3 years ago. Her pulse is 78/min, and blood pressure is 123/78 mm Hg. The uterine fundus is 15 em above the symphysis. The fetal
heart rate is 160/min. Which of the following is the most appropriate next step in management?

0 A) Schedule a routine return visit


0 B) Glucose tolerance test
0 C) Urine culture
@ D) Ultrasonography

0 E) Amniocentesis

1/15/201512:24 AM Screen dipping

NBME 2 OBGYN Page 20

Thursday, January 15,2015

12:24AM

Exam Section : Item 21 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 47 min 55 sec

21 . A 17-year-old primigravid patient at 34 weeks' gestation comes to the physician for a routine prenatal visit. She missed her last appointment 2 weeks ago. Pregnancy
has been uncomplicated. She notes good fetal movement and no contractions, vaginal bleeding, or loss of vaginal fluid. She has smoked two packs of cigarettes daily
for 3 years and has continued to smoke throughout pregnancy. She does not drink alcohol or use illicit drugs. She is 152 em (5 ft) tall and has gained 4.5 kg (10 lb)
during her pregnancy. Her blood pressure is 100/55 mm Hg. Examination shows a fundal height of 30 em. The fetal heart rate is 150/min. Which of the following is the
most appropriate next step in diagnosis?
@ A) Nonstress test

0 B) Fetal fibronectin test

C) Amniocentesis for Gram stain and culture

0 D) Amniocentesis for measurement of bilirubin concentration


0 E) Cordocentesis for measurement of fetal hemoglobin concentration

1/15/201512:24 AM Screen Oipping

FUNDAL HEIGHT IS TOO LOW, Growth restriction


Good fetal movement with no contraction= check a nonstress test to make sure baby is reactive. Mom's BP is 100/55 which is fine. Seems like
PPROM(?) with some vaginal bleeding, maybe due to the cigs.

I meant to say NO contraction, NO bleeding, NO loss offluid. l agree its A though. Growth restriction is seensogotta make sure baby is OK

NBME 2 OBGYN Page 21

Thursday, January 15,2015

12:24AM

Exam Section : Item 22 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 47 min 50 sec

22. A 32-year-old woman , gravida 3, para 2, at term is admitted to the hospital in labor. Contractions have occurred every 3 minutes for the past 8 hours. Her temperature is
37"C (98.6F), pulse is 80/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. The cervix is 100% effaced and 4 em dilated; the vertex is at - 2 station.
The membranes suddenly rupture, yielding a large amount of clear fluid . The fetal heart rate decreases to 90/min. Which of the following is the most appropriate next
step in management?
@ A) Pelvic examination

0
0
0
0
0

B) External cephalic version of the fetus


C) Internal podalic version of the fetus
D) Atropine therapy
E) Oxytocin therapy
F) Forceps delivery

1/15/201512:24 AM- Screen Oipping

pelvic exam... check for prolapsed cord, then do emergency C-section

NBME 2 OBGYN Page 22

Thursday, January 15,2015

12:24AM

Exam Section : Item 23 of 50


~ Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 47 min 46 sec

'

23. A 32-year-old nulligravid woman comes to the physician because she has been unable to conceive for 3 years. She has had irregular menses during this time. Her last
menstrual period was 11 weeks ago. She is otherwise healthy and takes no medications. She is 173 em (5 ft 8 in) tall and weighs 90 kg (198 lb); BMI is 30 kgJm2 Her
blood pressure is 128/70 mm Hg. Examination shows normal hair distribution and velvety pigmented skin over the axillae. There are no adnexal masses. This patient is
at increased risk for which of the following conditions?

0
0
0
0

A) Hypercalcemia
B) Hypercortisolism
C) Hyperthyroidism
D) Hypothyroidism
E) Premature ovarian failure

@ F) Type 2 diabetes mellitus

1/15/201512:24 AM- Screen Oipping

NBME 2 OBGYN Page 23

Thursday, January 15, 2015

12:24AM

Exam Section : Item 24 of 50


1r;1 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 47 min 42 sec

24. An asymptomatic 37-year-old woman with a 5-year history of HIV infection comes for a routine follow-up examination. Her last visit 8 months ago showed normal
find ings. A Pap smear 2 years ago showed no abnormalities. Her CD4+ T-lymphocyte count 2 weel<s ago was 425/mm 3 (Normal<::500); plasma HIV viral load was
undetectable. She is currently receiving antiretroviral therapy. Serum lipid studies were within normal limits 3 years ago. Examination today shows no abnormalities.
Which of the following is the most appropriate screening test for this patient?
@ A) Pap smear

0 B) Serum lipid studies


0 C) X-ray of the chest
0 D) ECG
0 E) Mammography

1/15/201512:24AM -Screen Clipping

NBME 2 OBGYN Page 24

25 foreign body
Thursday, January 15,2015

12:24AM

Exam Section : Item 25 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 47 min 37 sec

25. A 5-year-old girl is brought to the physician by her father 1 day after he noticed some blood on her underpants. He reports that she has been rubbing and scratching her
genital area for the past 5 days and that the irritation has progressed despite treatment with topical vitamin A & D and warm baths. On questioning, she says that she
has had a foul-smelling discharge and burning and itching in the area, which is worse when she urinates. She also has had a runny nose during this period. She has not
had fever and has no history of serious illness. Her temperature is 37"C (98.6F). Examination shows green vaginal discharge and diffuse inflammation of the vulva.
The hymen appears intact. There are no lacerations, ecchymoses, or other signs of trauma. A wet mount preparation of the discharge shows occasional erythrocytes
and numerous leukocytes. Culture of the discharge shows a polymicrobial infection. Which of the following is the most likely cause of these symptoms?

0
0
0
0

A) Gastroenteritis
B) Inoculation from an upper respiratory tract infection
C) Sarcoma botryoides
D) Urinary tract infection

@ E) Vaginal foreign body

1/15/201512:24 AM Screen Gipping


v~inal forei$n body (MCC of3reen valj"inal discharlj"C, bumin3 and itchin3 in a youl1lj" child= forei$n body such as toiletpaper or feces; absolutely worth rememberin3 as a similar
question appeared nearly verbatim on my actual shelfexam)

NBME 2 OBGYN Page 25

Thursday, January 15,2015

12:24AM

Exam Sect1on : Item 26 of 50


Mark

National Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

Time Remammg:
2 hr 47 min 33 sec

26. A 25-year-old nulligravid woman comes to the physician because she has not had a menstrual period for 1 year. Menarche was at the age of 13 years, and menses
initially occurred at regular 28-day intervals. Two years ago, menses began occurring at irregular, 45- to 90-day intervals until she eventually became amenorrheic. She
has no history of serious illness and takes no medications. She does not smoke cigarettes, drink alcohol, or use illicit drugs. She runs 7 miles daily and has completed
three marathons in the past year. She is not currently sexually active. She is 165 em (5 ft 5 in) tall and weighs 45 kg (100 lb); BM I is 17 kgfm 2. Physical examination
shows no abnormalities. Measurement of serum hormone concentrations is most likely to show which of the following?
@ A) Decreased estrogen and follicle-stimulating hormone (FSH) concentrations

0
0
0
0

B) Decreased estrogen and increased FSH concentrations


C) Normal estrogen and decreased FSH concentrations
D) Normal estrogen and increased FSH concentrations
E) Normal estrogen and increased prolactin concentrations

1/15/201512:24 AM- Screen dipping

NBME 2 OBGYN Page 26

Thursday, January 15, 2015

12:24AM

Exam Section : Item 27 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 47 min 29 sec

27. An 18-year-old nulligravid woman comes to the physician for a routine health maintenance examination. One year ago, her last examination, including laboratory
studies, showed no abnormalities. Her last menstrual period was 1 week ago. She has had multiple sexual partners and has used condoms inconsistently. Physical and
pelvic examinations show no abnormalities. HIV antibody testing and cultures for Neisseria gonorrhoeae and Chlamydia trachomatis are negative. Serologic testing for
VORL is positive at 1:4 . Which of the following is the most appropriate next step in diagnosis?

0 A) Antinuclear antibody assay


@ B) Fluorescent treponema! antibody absorption test

0 C) Rapid plasma reagin


0 D) Second VORL in 6 weeks
0 E) Lumbar puncture for VORL

1/15/2015 12:24AM Screen Clipping

NBME 2 OBGYN Page 27

Thursday, January 15,2015

12:24AM

Exam Section : Item 28 of 50


~ Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 47 min 24 sec

'

28. A 37-year-old woman , gravida 8, para 8, comes to the emergency department because of increasing vaginal bleeding over the past 5 hours. Abdominal examination
shows no abnormalities. Bimanual and rectal examinations show an 8-cm mass of the upper cervix and right parametrium. No ovary is palpated separately. ACT scan
shows a right hydroureter above the level of the mass. Which of the following is the most likely diagnosis?

0 A) Adenocarcinoma of the endometrium


0 B) Ovarian epithelial carcinoma
0 C) Peritoneal mesothelioma
@ D) Squamous cell carcinoma of the cervix

0 E) Transitional cell carcinoma of the bladder

1/15/201512:24 AM- Screen dipping

squamous cell carcinoma of the cervix associated with benign retroperitoneal fibrosis and hydroureters is reported.
1ncnt .:md ""''Tum~ :Jnd ~mprcu the ilix:

\-elo..".C...~. n

u: ..., ...,.nblc

rriJd .. of.ld,...m,cd (t.'C'\ k.tl (~l)(cr jo., ki:ltte bade.pain, h\'dnJtJrdc::r

...,,.) l<s $\\\'!ling.


cervical cancer... extending & obstructing the ureter. very common test presentation.

NBME 2 OBGYN Page 28

Thursday, January 15,2015

12:24AM

Exam Sect1on : Item 29 of 50


L'!ll Mark

Nat1onal Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 47 min 20 sec

29. Thirty-six hours after cesarean delivery because of prolonged labor, a 22-year-old woman has abdominal cramping and nausea and vomiting. Her temperature is
38.8C (101.8F), pulse is 98/min, and blood pressure is 110/64 mm Hg. Examination shows diffuse lower abdominal tenderness with some voluntary guarding but no
rebound. The incision is clean , dry, and intact. Her leukocyte count is 15,000/mm 3. A urinary catheter is in place; urinalysis shows multiple RBCs. Which of the following
is the most appropriate next step in management?

0 A) CT scan of the pelvis


0 B) Intramuscular administration of methylergonovine
@ C) Intravenous administration of ampicillin and gentamicin

0 D) Dilatation and curettage


0 E) Surgical exploration

1/15/201512:24 AM Screen dipping

Give ABX. RBCs in the urine is normal with a catheter. that**** is traumatic and irritating the epithelium. Uterine tenderness+ fever this close
post op is endometritis until proven otherwise.

NBME 2 OBGYN Page 29

Thursday, January 15,2015

12:2SAM

Exam Section : Item 30 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 47 m in 7 sec

lAO

1-

30. A 19-year-old primigravid woman at term has been in labor for 16 hours. Her membranes have been ruptured for 11 hours, and she has had nine vaginal examinations. Her temperature
is 38.4C (101.1 oF), pulse is 90/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. A fetal heart tracing is shown. Which of the following is most likely responsible for
the results shown in the tracing?

0
0

A) Fetal anemia
B) Fetal head compression

@ C) Maternal fever
D) Umbilical cord compression
E) Uteroplacental insufficiency

0
0

1/15/201512:25 AM Screen dipping

NBME 2 OBGYN Page 30

31
Thursday, January 15,2015

12:2SAM

Exam Sect1on : Item 31 of 50


1.!:.iJ Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaimng:
2 hr 47 min 0 sec

31. A 27-year-old primigravid woman at 14 weeks' gestation comes to the physician for an initial prenatal visit. Endovaginal examination shows a viable twin gestation consistent in size with
an 8-week gestation. There are two yolk sacs and a thick dividing membrane. An ultrasound is shown. This patient most likely has which of the following types of twin gestation?

A) Conjoined
@ B) Dichorionic
0 C) Monochorionic
0 D) Monochorionic-monoamniotic
0 E) Findings are inconclusive at this gestational age

1/15/201512:25 AM- Screen Oipping

Could have been monochroionic with two yolk sacs but would be thin dividing membrane.
Features supporting a DCDA pregnancy:
presence of t w o gestational sacs with a thick echogenic chorion surrounding each embryo
a thick inter twin membrane
twin peak sign
two yolk sacs may be seen (this however does not differentiate a DCDA pregnancy from a monochorionic dia mniotic ( MCDA) pregnancy)

NBME 2 OBGYN Page 31

Thursday, January 15,2015

12:2SAM

Exam Section : Item 32 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 46 min 53 sec

32. A 21-year-old primigravid woman at 40 weeks' gestation is admitted in labor. The cervix is 100% effaced and 5 em dilated. Leopold maneuvers show the fetus in a
transverse lie presentation with the back toward the pelvis. Which of the following is the most appropriate next step in management?

0
0
0
0

A) Await spontaneous vaginal delivery


B) Administration of oxytocin
C) Tocolytic therapy
D) Internal version and breech extraction

@ E) Cesarean delivery

1/15/201512:25 AM- Screen Oipping

Could try external version if not in labor.

NBME 2 OBGYN Page 32

Thursday, January 15,2015

12:2SAM

Exam Section : Item 33 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 46 min 47 sec

33. A 47-year-old woman comes to the physician for a routine health maintenance examination. She says that she sometimes feels hot at night and occasionally during the
day. She has not had any other symptoms. She has no history of serious illness and takes no medications. Her last menstrual period was 4 months ago. She is sexually
active with one male partner, and they do not use contraception. She is 168 em (5 ft 6 in) tall and weighs 68 kg (150 Ib); BMI is 24 kgfm2 Her temperature is 37.1 oc
(98.7"F), pulse is 70/min, respirations are 12/min, and blood pressure is 90/50 mm Hg. She has moderate discomfort during the pelvic examination because of vaginal
dryness. The uterus is enlarged and mildly boggy. There are no vulvar, vaginal, or cervical lesions or adnexal masses. The remainder of the examination shows no
abnormalities. Test of the stool for occult blood is negative. Which of the following is the most appropriate next step in diagnosis?

A) Complete blood count

0 B) Measurement of serum follicle-stimulating hormone concentration


@ C) Measurement of serum 13-hCG concentration

0 D) Measurement of serum prolactin concentration


0 E) Measurement of serum thyroid-stimulating hormone concentration

1/15/201512:25 AM- Screen Oipping

NBME 2 OBGYN Page 33

34
Thursday, January 15,2015

12:2SAM

Exam Section : Item 34 of 50


1.!11 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 46 min 43 sec

34. A 24-year-old primigravid woman at term is admitted to the hospital in labor. She has not been screened for group B streptococcal infection. Pregnancy has been
uncomplicated. The cervix is 80% effaced and 5 em dilated; the vertex is at +1 station. Contractions occur every 10 minutes. The membranes ruptured 12 hours ago.
Examination shows areas of vag inal erythema. Cultures for group B streptococcal infection are pending. Which of the following is the most appropriate next step
regard ing prevention of group B streptococcal sepsis in the newborn?
@ A) Antibiotic therapy if delivery has not occurred 18 hours after rupture of membranes

0 B) Antibiotic therapy if the fetal heart rate exceeds 180/min


0 C) Antibiotic therapy if Gram stain of amniotic fluid is positive
0 D) Forceps delivery if second stage of labor exceeds 2 hours

E) Cesarean delivery because lesions are present

1/15/201512:25 AM- Screen dipping

NBME 2 OBGYN Page 34

Thursday, January 15,2015

12:2SAM

Exam Section : Item 35 of 50

Nat1onal Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaming:
2 hr 46 min 39 sec

35. A 47-year-old woman , gravida 2, para 2, comes to the physician because of a 9-month history of irregular menstrual periods and bleeding between menses. Menses
now occur at 2- to 3-month intervals and last 10 days. She has hypertension. She has smoked two packs of cigarettes daily for 30 years. Her blood pressure is
160/90 mm Hg. Pelvic examination shows no abnormalities. Results of an endometrial biopsy specimen show proliferative endometrium. Which of the following is the
most appropriate next step in management of this patient's irregular menstrual periods?

0 A) Bromocriptine therapy
0 B) Combination oral contraceptive therapy
@ C) Cyclic progestin therapy

0
0
0
0

D) Estrogen replacement therapy


E) Laparoscopy
F) Dilatation and curettage
G) Myomectomy

1/15/201512:25 AM- Screen dipping

NBME 2 OBGYN Page 35

Thursday, January 15,2015

12:2SAM

Exam Section : Item 36 of 50


L!,l Mark

Nat1onal Board of Medical Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 46 min 34 sec

36. A 20-year-old primigravid woman at 20 weeks' gestation comes for a routine prenatal visit. She works in a day-care center. Her pregnancy was complicated by a small
amount of vaginal bleeding during the first trimester that resolved spontaneously. Her sister recently had a child who was diagnosed with cystic fibrosis soon after
delivery. She appears well. Examination shows a nontender uterus consistent in size with a 20-week gestation. Laboratory studies are within normal limits. Her blood
group is A, Rh-negative. Antibody screening is negative. Ultrasonography shows a single intrauterine pregnancy with fetal hydrops; no structural abnormalities are
noted. Which of the following is the most likely cause of the fetal hydrops?

0 A) Cytomegalovirus
0 B) Fetal cystic fibrosis
@ C) Fetal parvovirus 819 infection

0 D) Maternal Chlamydia trachomatis infection


0 E) Rh sensitization

1/15/201512:25 AM Screen dipping

NBME 2 OBGYN Page 36

Thursday, January 15,2015

12:2SAM

Exam Section : Item 37 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 46 min 29 sec

37. A 32-year-old nulligravid woman comes to the physician with her 34-year-old husband because she has been unable to conceive for 3 years. Menarche was at the age
of 12 years, and menses occur at regular 28-day intervals. She used an oral contraceptive for 3 years. She has had multiple sexual partners. Pelvic examination shows
no abnormalities. Cervical cultures are negative. Her husband's semen analysis is within normal limits. Which of the following is the most appropriate next step in
diagnosis?

0 A) Endometrial biopsy
@ B) Hysterosalpingography

0 C) Karyotype analysis
0 D) Laparoscopy
0 E) Measurement of serum follicle-stimulating hormone concentration

1/15/201512:25 AM Screen Oipping

NBME 2 OBGYN Page 37

0
0
0
0
0

F) Measurement of serum luteinizing hormone concentration


G) Measurement of serum progesterone concentration
H) Postcoital test
I) Progesterone challenge test
J) Sperm antibody testing

38 Friction rub
Thursday, January 15,2015

12:26 AM

Exam Section : Item 38 of 50


Mark

Nat1onal Board of Medical Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 46 min 7 sec

("'38. Three days after cesarean delivery because of fetal distress, a hospitalized 42-year-old woman is found unconscious. She is 163 em (5 ft 4 in) tall and weighs 82 kg
(180 Ib); BMI is 31 kgfm2. Her temperature is 38C (100.4F), pulse is 120/min, respirations are 26/min, and blood pressure is 60/40 mm Hg. Bilateral wheezing is
heard on auscultation. Cardiac examination shows a pleural friction rub. The fundus is firm. Laboratory studies show:
Hemoglobin
Leukocyte count
Platelet count
Bleeding time
Prothrombin time
Partial thromboplastin t ime
Thrombin time
Plasma fibrinogen
Fibrin split products

11 g/dL
8000/mm3
175,000/mm3
5 min
14 sec (INR=1.4)
35 sec
1 sec
300 mg/dL
(N =200-400)
<10 IJg/mL (N<10)

Arterial blood gas analysis on room air shows:


7.26
28 mm Hg
60 mm Hg
A blood smear shows no abnormalities. An x-ray of the chest shows atelectasis. An ECG shows tachycardia with cor pulmonale. Which of the following is the most
likely diagnosis?

1/15/201512:26 AM Screen Oipping

@ A) Amniotic fluid embolism

0 B) Cardiac arrhythmia
0 C) Cerebral hemorrhage

0
0
0

D) Congestive heart failure


E) Eclampsia
F) Hypovolemic shock

0
0
~

0
0
0

G) Pneumonitis
H) Pneumothorax
I) Pulmonary acid aspiration syndrome
J) Pulmonary embolism

K) Seizure disorder
L) Septic shock

PUlMONARY EMBOliSM most likely. Pleural rub is sign of pulmonary embolism


NOT AOR i

NBME 2 OBGYN Page 38

Thursday, January 15,2015

12:26AM

Exam Section : Item 39 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 45 min 47 sec

39. Three days after a cesarean delivery because of cephalopelvic disproportion, a 27-year-old woman has a temperature of 38.4C (1 01.1 F). She has no cough,
shortness of breath, urinary frequency or urgency, or dysuria. Her labor lasted 18 hours. The lungs are clear to auscultation. The abdomen is soft without rebound.
Examination of the incision shows erythema and induration. There is minimal tenderness of the uterus on palpation and no costovertebral angle tenderness. Laboratory
studies show:
Leukocyte count
Segmented neutrophils
Eosinophils
Lymphocytes
Monocytes
Urine WBC
Which of the following is the most likely cause of this patient's fever?

0
0
0
0
0

A) Appendicitis
B) Calculous cholecystitis
C) Diverticular abscess
D) Pneumonia
E) Postpartum endometritis

0
0
0
0

F) Pyelonephritis
G) Septic pelvic thrombophlebitis
H) Urinary tract infection
I) Viral gastroenteritis

@ J) Wound infection

1/15/201512:26 AM- Screen dipping

NBME 2 OBGYN Page 39

14,800/mm3
87%
3%
5%
5%

5- 10/hpf

40 Ectopic?
Thursday, January 15, 2015

12:26AM

Exam Sect1on : Item 40 of 50

Nat1onal Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remainmg:
2 hr 45 min 42 sec

40. A 32-year-old primigravid woman at 6 weeks' gestation comes to the physician because of a 3-day history of moderate vaginal bleeding. She was seen in the
emergency department 1 week ago with similar symptoms. Pelvic ultrasonography at that time showed a thickened endometrial stripe and no fetal pole. Her serum
~- hCG concentration was 450 miU/mL. Today, her pulse is 80/min, and blood pressure is 110/60 mm Hg. Pelvic examination shows a closed cervix and a nontender
uterus consistent in size with a 6-week gestation. There are no palpable adnexal masses. Today, her hemoglobin concentration is 11 .8 g/dl, and serum 13-hCG
concentration is 90 miU/mL. Which of the following is 1he most appropriate next step in management?

0 A) Third measurement of serum

~-hCG

concentration in 1 week

@ B) Administration of methotrexate

0 C) Progesterone suppositories
0 D) Admission to the hospital
0 E) Endometrial biopsy

-1--

1/15/2015 12:26 AM Screen Clipping

A) Third measurement of serumBHCG in 1 week. She had an abortion. Afte r abortion,


measure serum hCG level weekly until it is undetectable.

NBME 2 OBGYN Page 40

Thursday, January 15,2015

12:26AM

Exam Section : Item 41 of 50


Mark

Nat1onal Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 45 min 37 sec

41 . A 32-year-old nulligravid woman with bipolar disorder comes to the physician for preconceptional counseling. Her symptoms are well controlled with valproic acid, and
she does not want to discontinue her medication. Physical examination shows no abnormalities. On mental status examination, her affect is full; there is no pressured
speech or flight of ideas. Her future child will be at greatest risk for developing which of the following abnormalities if she continues to take valproic acid throughout
pregnancy?

0 A) Cleft palate
@ B) Neural tube defects

0 C) Retinitis pigmentosa
0 D) Syringomyelia

E) Tetralogy of Fallot

1/15/201512:26 AM- Screen Oipping

NBME 2 OBGYN Page 41

Thursday, January 15, 2015

12:26 AM

-------------------------------------------------------------------------------------------------------------------------------------

Exam Section : Item 42 of 50


Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 45 min 33 sec

42. A 24-year-old woman , gravida 3, para 3,. comes to the physician because she has not had a menstrual period since the birth of her third child 13 months ago by vaginal
delivery. Delivery was complicated by postpartum hemorrhage requiring dilatation and curettage. She breast-fed the infant for 4 months. She has a long-standing history
of bloating and mood changes with menses. She has no other history of serious illness. She is sexually active with her husband and uses condoms for contraception.
She is 165 em (5 ft 5 in) tall and weighs 75 kg (165 lb); BMI is 28 kgfm2. Her temperature is 36.9C (98.5F), pulse is 64/min, and blood pressure is 120/70 mm Hg.
Examination shows a normal-sized thyroid. Breast, abdominal, and pelvic examinations show no abnormalities. Her serum thyroid-stimulating hormone, foll iclestimulating hormone, and prolactin concentrations are within the reference range. Qualitative serum ~-hCG testing is negative. A progestin challenge test shows no
withdrawal bleeding. Which of the following is the most likely diagnosis?
@ A) Asherman syndrome

0 B) Hyperprolactinemia
0 C) Hypothalamic-pituitary dysfunction
0 D) Pregnancy

E) Premature ovarian failure

1/15/2015 12:26 AM Screen Clipping

NBME 2 OBGYN Page 42

Thursday, January 15,2015

12:26AM

Exam Section : Item 43 of 50


L!,l Mark

Nat1onal Board of Medical Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 45 min 28 sec

43. A healthy 37-year-old woman, gravida 2, para 2, comes to the physician for contraceptive advice. She is sexually active with her husband, and they currently use
condoms but would like to switch to another contraceptive method. She has smoked one pack of cigarettes daily for 20 years. She has no history of sexually transmitted
diseases, high blood pressure, headaches, venous thromboembolism, or depression. Testing for Neisseria gonorrhoeae and Chlamydia trachomatis is negative. Which
of the following contraceptive methods is contraindicated in this patient?

0
0
0
0
0

A) Copper IUD
B) Depot medroxyprogesterone
C) Diaphragm
D) Norethindrone pills
E) Progesterone IUD

@ F) Triphasic oral contraceptives

1/15/201512:26 AM Screen Oipping

NBME 2 OBGYN Page 43

Thursday, January 15,2015

12:26AM

Exam Section : Item 44 of 50

Nat1onal Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaming:
2 hr 45 min 25 sec

44. An otherwise healthy 14-year-old girl is brought to the physician by her mother because of a 10-day history of profuse, green, foul-smelling vaginal discharge. Menarche
was at the age of 12 years, and menses occur at regular 28-day intervals. Her last menstrual period was 3 weeks ago. She takes no medications and has no known
drug allergies. She does not smoke cigarettes, drink alcohol, or use illicit drugs. She recently has had several unexcused absences from school. Her temperature is
3JOC (98.6F), pulse is 78/min, and blood pressure is 98/54 mm Hg. Breast and pubic hair development are Tanner stage 3. Abdominal examination shows no masses
or tenderness. Pelvic examination shows petechiae on the vag inal mucosa, and abundant, foul-smelling, frothy green discharge in the vaginal vault; no foreign body can
be visualized. There is a large ectropion on the cervix. The external genitalia, uterus, and adnexa are normal. Which of the following is the most appropriate next step?

0 A) Reassurance and fol low-up visit in 4 months


0 B) Culture of the vaginal fluid
0 C) Cytologic examination of the vaginal fluid
@ D) Wet mount preparation of the vaginal fluid

0 E) Cervical biopsy
0 F) Vaginal wall biopsy

1/15/201512:26 AM Screen dipping

NBME 2 OBGYN Page 44

Thursday, January 15,2015

12:27 AM

Exam Section : Item 45 of 50


L!,l Mark

Nat1onal Board of Medical Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 45 min 19 sec

45. A 27-year-old woman who recently emigrated from Uganda comes to the physician 14 days after she noticed a painful sore in her vagina. She has no history of serious
illness or surgical procedures. Menses occur at irregular 45-day intervals. Her last menstrual period was 20 days ago. She had been sexually active with multiple
partners and uses depot medroxyprogesterone. Her temperature is 38C (1 00.4F). Pelvic examination shows a raw, deep, exquisitely tender ulcer at the introitus with
an uneven base and inflamed undermined margins. Which of the following is the most likely causal organism?

0
0

A) Calymmatobacterium granulomatis

D) Treponema pallidum

E) Trichomonas vagina/is

B) Chlamydia trachomatis
@ C) Haemophi/us ducreyi

1/15/201512:27 AM- Screen Gipping

NBME 2 OBGYN Page 45

Thursday, January 15,2015

12:27 AM

Exam Section : Item 46 of 50


L!,l Mark

Nat1onal Board of Medical Exammers


Obstetrics and Gynecology Self-Assessment

Time Remaming:
2 hr 45 min 15 sec

46. A 17-year-old primigravid patient at 41 weeks' gestation comes to the physician for a routine prenatal visit. She is accompanied by the father of the child. Pregnancy
has been uncomplicated. Examination shows a uterus consistent in size with a 41-week gestation. The physician recommends initiating twice weekly nonstress testing
with planned induction of labor at 42 weeks' gestation to prevent fetal morbidity and mortality. After discussing the indications, risks, and benefits of the recommended
testing and induction, the patient refuses the recommendations. Which of the following is the most appropriate response?

0 A) Ask the father if he agrees with the patient's decision


0 B) Obtain informed consent from the patient's parents for induction of labor at 42 weeks' gestation
0 C) Obtain psychiatric assessment to determine the patient's decision-making capacity
@ D) Respect the patient's wishes and schedule a follow-up visit in 1 week

0 E) Transfer the patient to a physician who feels comfortable with her decision

1/15/201512:27 AM- Screen Oipping

NBME 2 OBGYN Page 46

47
Thursday, January 15,2015

12:27 AM

Exam Section : Item 47 of 50

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

~Mark

Time Remaining:
2 hr 45 min 11 sec

47. A 42-year-old woman undergoes amniocentesis and is informed that the fetal karyotype is 46,XX. At birth , the full-term newborn has a phallus and scrotum. Which of
)(-' the following is the most likely explanation for the discrepancy between the amniocentesis finding and the physical finding?

0 A) ACTH oversecretion
0 B) Androgen insensitivity syndrome
0 C) Fusion of two monozygotes
@ D) Lyonization of gene expression

1/15/201512:27 AM Screen dipping

Congenital adrenal hyperplasia. Also get acth over secretion.


All congenital adrenal enzyme deficiencies are characterized by an enlargement of both adrenal
glands due to increased ACTH stimulation (due to decreased cortisol).
NOT CORD

NBME 2 OBGYN Page 4 7

Thursday, January 15,2015

12:27 AM

Exam Section : Item 48 of 50


L'!'J Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 45 min 7 sec

48. A 32-year-old primigravid woman at 32 weeks' gestation comes to the physician for a routine prenatal visit. She has hypertension treated with nifedipine and
hypothyroidism controlled with levothyroxine. Four weeks ago at her last examination, fundal height was lagging. She was started on an 1800-calorie diet after results of
a 3-hour glucose tolerance test showed abnormalities. She is 157 em (5 ft 2 in) tall. She has had a 9-kg (20-lb) weight gain during her pregnancy. Her pulse is 92/min,
and blood pressure is 160/96 mm Hg. Examination shows a fundal height of 27 em. During the past 2 weeks, her blood glucose concentrations have been less than
120 mg/dl 1 hour after meals. Ultrasonography shows an estimated fetal weight at the 5th percentile for 32 weeks' gestation. Which of the following is the most likely
cause of the fetal growth restriction?

0 A) Gestational diabetes

B) Maternal hypothyroidism

0 C) Maternal malnutrition
0 D) Umbilical cord compression
@ E) Uteroplacental insufficiency

1/15/201512:27 AM- Screen Oipping

Primary placental insufficiency may be the most common cause of IUGR, but it is a diagnosis of exclusion.

NBME 2 OBGYN Page 48

49
Thursday, January 15,2015

12:27 AM

Exam Section : Item 49 of 50


1!2 Mark

National Board of Medical Examiners


Obstetrics and Gynecology Self-Assessment

Time Remaining:
2 hr 45 min 2 sec

49. A 23-year-old woman comes to the emergency department because of the acute onset of intense, right-sided lower abdominal pain for 18 hours; the pain was initially
intermittent but has been constant for 3 hours. Her last menstrual period was 6 weeks ago. Menses occur at irregular 32- to 50-day intervals. A 5 x 5 x 4-cm mass in
the right adnexa was found after a mild episode of pain 3 weeks ago. She has not been sexually active for 6 months. Her temperature is 37.8C (100F), pulse is
100/min, respirations are 18/min, and blood pressure is 138/92 mm Hg. Abdominal examination shows tenderness in the right lower quadrant with rebound and
guarding. Pelvic examination cannot be performed because of discomfort. Ultrasonography of the abdomen shows a 10 x 8 x 7-em right-sided mass with cystic and
solid components. Which of the following is the most likely diagnosis?

0 A) Appendiceal abscess
0 B) Chronic ectopic pregnancy
0 C) Ruptured ovarian cyst
@ D) Torsion of an ovarian cyst

0 E) Tube-ovarian abscess

1/15/201512:27 AM- Screen dipping

Ultrasonography doesn't show ruptured cyst (ultrasound doesn't show fluid in the pelvis?).

NBME 2 OBGYN Page 49

Thursday, January 15,2015

12:27 AM

Exam Sect1on : Item 50 of 50


Mark

National Board of Med1cal Exammers


Obstetrics and Gynecology Self-Assessment

Time Remammg:
2 hr 44 min 57 sec

50. An asymptomatic 59-year-old woman comes for a routine health maintenance examination. Menopause occurred at the ag:e of 49 years. She is 163 em (5 ft 4 in) tall
and weighs 91 kg (200 lb); BM I is 34 kgfm2. Her risk for endometrial cancer is increased due to peripheral conversion of which of the following?

0 A) Aldosterone to diethylstilbestrol
@ B) Androstenedione to estrone

0 C) Androstened ione to mestranol


0 D) Pregnenolone to progesterone
0 E) Progesterone to estradiol

1/15/201512:27 AM Screen dipping

NBME 2 OBGYN Page 50