Exam Section : item 1 of 50 National Board of Medical Examiners Time 3 maining:

1. A 32-year-old primigravid woman comes to the physician at 30 weeks' gestation because of a 10-day history of decreased appetite, intermittent nausea, and generalized itching. She has no history of serious
illness, and her pregnancy has been otherwise uncomplicated. Her pulse is 98/min and regular, and blood pressure is 104/64 mm Hg. Examination shows excoriations on the left shoulder. The lungs are clear
to auscultation. A grade 2/6 systolic murmur is heard best at the left sternal border. The uterus is consistent in size with a 30-week gestation. Laboratory studies show:
Hemoglobin 11 g/dL
Mean corpuscular volume 86 pm3
Leukocyte count 10,200/mm3
Platelet count 114.000/mm3
Red cell distribution width 13% (N=13% -15%)
Serum
Total bilirubin 2.1 mg/dL
Alkaline phosphatase 206 U/L
AST 30U /L
ALT 26 U/L

Abdominal ultrasonography shows no abnormalities. Which of the following is the most likely explanation for her symptoms?

A) Acute fatty liver

B) HELLP syndrome
C) Intrahepatic cholestasis
D) Mastocytosis
© E) Normal pregnancy
Exam Section : Item 2 of 50 National Board of Medical Examiners Time Remainin
m Mark_______________________________________________________________________________ Obstetrics & Gynecology Self-Assessment__________________________________________________________________ 4 hr 59 min 4 s

2. A 47-year-old woman comes to the emergency department because of a 4-day history of increasing pain with urination. Five days ago, she began treatment
with a sulfonamide antibiotic by her primary physician after a phone consultation: she has not had relief of her symptoms. She has no history of serious
illness, abnormal Pap smears, or sexually transmitted diseases. She currently takes no medications. She states that she has had increasing stress during
the past month. Pelvic examination shows an exquisitely tender ulcer on the lower labium minus. A photograph of the lower labia is shown. Which of the
following is the most likely diagnosis?

A) Candidiasis
B) Condyloma acuminatum
S; C) Flerpes simplex virus 1
D) Molluscum contagiosum
E) Paget disease
Exam Section : Item 3 of 50 National Board of Medical Examiners Time Renr
■ Marb Obstetrics & Gynecology Self-Assessment 4 hr 57 m

3. A 21-year-old primigravid woman at 10 w eeks' gestation has had severe nausea and has been unable to keep anything in her stomach fo r 48 hours. She has had mild nausea and vomiting fo r 6 weeks.
Examination shows normal findings. Ultrasonography shows a normal 10-week gestation. Which o f the following is the most appropriate next step in diagnosis?

A) Complete blood count

4 B) Measurement o f serum bilirubin concentration
C) Measurement of serum glucose concentration
5 D) Measurement o f urinary ketones
E) Measurement o f urinary protein
Exam Section : Item 4 of 50 National Board of Medical Examiners Time Remal
■ Obstetrics & Gynecology Self-Assessment 4 hr 57 min

4. A 23-year-old woman comes to the physician because o f a 3-day history of pain and burning with urination. Two years ago. she had similar symptoms that resolved with trimethoprim-sulfamethoxazole
therapy. She is sexually active and uses an oral contraceptive. Her temperature is 37°C (98.6°F). Examination shows no costovertebral angle tenderness. Urinalysis shows bacteria and pus. She requests
advice about preventing future episodes. Which o f the following is the most appropriate recommendation?

€■ A) Drinking 6 ounces of cranberry juice daily

€ B) Voiding immediately after coitus
€> C) Antibiotic prophylaxis only after coitus
D) Daily trimethoprim-sulfamethoxazole prophylaxis
€■■ E) No preventive measures available
Exam Section : Item 5 of 50 National Board of Medical Examiners
■ Marti___________________ Obstetrics & Gynecology Self-Assessment

5. A 27-year-old woman comes to the physician because of a 4-month history of increasingly severe pain during her menstrual periods. Menses occur at regular 28-day intervals and last 5 to 7 days with light
flow. Her last menstrual period was 25 days ago. She underwent a loop electrosurgical excision of the cervical transformation zone for cervical dysplasia 6 months ago; examination of the biopsy specimen
showed cervical intraepithelial neoplasia (CIN) 2 with negative margins. She is sexually active and uses condoms and spermicidal foam. Pelvic examination shows a normal vagina and a small, scarred cervical
os. The uterus is slightly enlarged and tender. Which of the following is the most likely cause of this patient's symptoms?

€> A) Cervical stenosis

€ B) Endometritis
# C) Premenstrual syndrome
€ D) Recurrent dysplasia
€ E) Threatened abortion
Exam Section : Item 6 of 50 National Board of Medical Examiners Time Remaining
■ Mark Obstetrics & Gynecology Self-Assessment 4 hr 53 min 14 s

6. A 37-year-old woman, gravida 1. para 1. comes to the physician for a follow-up examination. Six weeks ago, a Pap smear showed low-grade intraepithelial lesions. She has had no symptoms and takes no
medications. She is sexually active with one partner and uses a diaphragm for contraception. Examination shows a normal vagina, cervix, and uterus. Colposcopic examination shows an acetowhite area with
punctation. The entire squamocolumnar junction cannot be visualized. A biopsy specimen of the cervix shows cervical intraepithelial neoplasia (CIN) 3. Which of the following is the most appropriate next step in
management?

€ ' A) Monthly Pap smears over the next 3 months

4 B) Second colposcopy in 3 months
4 C) Hysteroscopy
# D) Cone biopsy of the cervix
4 E) Cryotherapy of the cervix
® F) Vaginal hysterectomy
Exam Section : Item 7 of 50 National Board of Medical Examiners Time Remalnin
■ Mark Obstetrics & Gynecology Self-Assessment 4 hr 52 min 40

7. A 16-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She also has had moderate lower abdominal pain during the past 5 months. She has no history of
serious illness and takes no medications. She is 163 cm (5 ft 4 in) tall and weighs 52 kg (115 lb): BMI is 20 kg/m-. Breast development is Tanner stage 4. Examination shows coarse pubic and axillary hair.
The external genitalia appear normal. The vaginal canal cannot be visualized. Rectal examination shows an anterior tender, central mass. Which of the following is the most likely explanation for these findings?

«■ A) Androgen insensitivity syndrome

€ B) Complete mijllerian agenesis
® C) Hormonally active ovarian tumor
€ D) Imperforate hymen
€ E) Normal development
Exam Section : Item 8 of 50 National Board of Medical Examiners Time Remalnir
■ Mark Obstetrics & Gynecology Self-Assessment 4 hr 51 min 59

8. A 32-year-old woman with type 1 diabetes mellitus has had increasingly severe perineal pain over the past 3 days. Her temperature is 39°C (102.2°F). Pelvic examination shows a 5 * 5-cm tense cystic mass
in the posterior right labium majus with cellulitis extending past the right pubic hairline. Which of the following is the most serious complication of this condition?

A) Bartholin gland abscess

€ B) Chlamydial sepsis
C) Gram-positive sepsis
D) Necrotizing fasciitis
# E) Perirectal abscess
Exam Section : Item 9 of 50 National Board of Medical Examiners TimeR
■ Mori, Obstetrics & Gynecology Self-Assessment 4 hr 50 min 5G

9. A 12',4-year-old girl is brought to the physician because she has not had a menstrual period for 5 months. Menarche was at the age o f 11 years, and menses had occurred at irregular 30- to 90-day intervals
and lasted 1 to 5 days. She plays softball in the spring and participates in physical education class at school tw o times weekly. She is not sexually active. She is at the 60th percentile for height and
40th percentile for weight. Examination shows no abnormalities. Which of the following is the most likely diagnosis?

® A) Anorexia nervosa
€ B) Athletic amenorrhea
# C) Congenital adrenal hyperplasia
€ D) Hyperthyroidism
€ E) Hypothyroidism
# F) Polycystic ovarian syndrome
# G) Prolactin-secreting tumor
C H) Normal development
Exam Section : item 10 of 50 National Board of Medical Examiners HUgne Renta
Obstetrics & Gynecology Self-Assessment 4 hr 50 min
■ Mark__________________

10. An 18-year-old woman comes to the physician because of irregular menses over the past 3 months; menses occur at 14- to 40-day intervals. Menstrual flow varies from spotting to heavy cramping and
bleeding; the latter symptoms have caused her to miss school. Her last menstrual period was 3 weeks ago. Menarche was at the age of 12 years, and menses had occurred at regular 28-day intervals for
6 years. She has a sedentary lifestyle. She is 165 cm (5 ft 5 in) tall and weighs 63 kg (139 lb); BMI is 23 kg/m 2. Pelvic examination shows no abnormalities. A urine pregnancy test is negative. Which o f the
following is the most appropriate next step in management?

O A) Conjugated estrogen therapy

® B) Cyclic progesterone therapy
® C) Hysteroscopy
0 ) Endometrial biopsy
E) Dilatation and curettage
Exam Section : Item 11 of 50 National Board of Medical Examiners Time Remainii
M Mark
Obstetrics & Gynecology Self-Assessment 4 hr 47 min 44

The response options for the next 2 items are the same. Select one answer for each item in the set.

For each patient with a fetus or newborn with abnormalities, select the maternal condition most likely associated with these findings.

® A) Alcohol use H) Heroin use

9 B) Amphetamine use I) Iodine deficiency
C) Cigarette smoking J) Marijuana use
# D) Cocaine use K) Parvovirus B19 infection
E) Cystic fibrosis carrier state L) Rh sensitization
® F) Folic acid deficiency M) Rubella infection
G) Gametic nondisjunction N) Tay-Sachs carrier state

11. A 27-year-old primigravid woman at 19 weeks' gestation comes for a routine prenatal visit. She works in a preschool. Pregnancy has been uncomplicated except for mild gastrointestinal symptoms 6 weeks
ago. She has an abnormal triple screen study prompting ultrasonography that shows fetal hydrops and ascites.
Exam Section : Item 12 of SO

For each patient with a fetus or newborn with abnormalities, select the maternal condition most likely associated with these findings.

® A) Alcohol use i H) Heroin use

9 B) Amphetamine use
C) Cigarette smoking
D) Cocaine use
E) Cystic fibrosis carrier state
9 F) Folic acid deficiency
G) Gametic nondisjunction
1) Iodine deficiency
® J) Marijuana use
9 K) Parvovirus B19 infection
fa L) Rh sensitization
€ M) Rubella infection
t N) Tay-Sachs carrier state

12. A 19-year-old primigravid woman comes to the emergency department because of vaginal bleeding, abdominal pain, and lethargy fo r 4 hours. She has had no prenatal care. She is unable to give a history.
Her pulse is 112/min. respirations are 18/min. and blood pressure is 190/108 mm Hg. Abdominal examination shows a fundal height o f 27 cm. The abdomen is rigid and tender to palpation.
Exam Section : item 13 of 50 National Board of Medical Examiners Time Remaimr
■ Mark Obstetrics & Gynecology Self-Assessment 4 hr 45 min 55

13. A 27-year-old primigravid woman at 38 weeks' gestation is admitted to the hospital in labor. She had spontaneous rupture of membranes 2 days ago. On arrival, her temperature is 39.1 °C (102.3°F). The
cervix is 100% effaced and 4 cm dilated; the vertex is at +1 station. Abdominal examination shows exquisite tenderness o f the uterine fundus. Pelvic examination shows mucopurulent cervical discharge. The
fetal heart rate is 180/min with good variability. Treatment with intravenous ampicillin and gentamicin is begun. Two hours after admission, the cervix remains 4 cm dilated. She undergoes cesarean delivery
for arrest o f active phase and delivers a healthy newborn. Six hours after delivery, the patient's temperature is 38.9°C (102° F). Which of the following is the most likely cause of this patient's fever?

# A) Chlamydia trachomatis infection

# B) Escherichia coli infection
C) Neisseria gonorrhoeae infection
D) Polymicrobial infection
# E) Septic pelvic thrombophlebitis
Exam Section : Item 14 of 50 National Board of Medical Examiners ilme Remaining
■ Mark_________________ Obstetrics & Gynecology Self-Assessment 4 hr 44 min 20 i

14. A 42-year-old woman with systemic lupus erythematosus comes to the physician for a follow-up examination. Two weeks ago. prednisone therapy was begun because of a flare-up of her disease; this is her
third course of prednisone during the past 18 months. Today, the patient is feeling well. Menses occur at regular 28-day intervals. Her only other medications are vitamin D and calcium. She has no other
history of serious illness, and there is no family history of serious illness. She has no known allergies. She does not smoke cigarettes or drink alcohol. She is 165 cm (5 ft 5 in) tall and weighs 63 kg (140 lb);
BMI is 23 kg/m2. Her pulse is 70/min, and blood pressure is 108/64 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate pharmacotherapy to prevent osteoporosis in
this patient?

A) Alendronate now
4 B) Calcitonin now
C) Estrogen and progesterone now
• D) Estrogen alone at the onset of menopause
9 E) Raloxifene now
Exam Section : Item 15 of 50 National Board of Medical Examiners Time Remalr
■ Mart, Obstetrics & Gynecology Self-Assessment 4 hr 43 min 1

15. A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive fo r 3 years. Menses occur at irregular 35- to 42-day intervals and last 8 days. Laparoscopy 8 weeks ago
showed spill from both fallopian tubes after methylene blue dye was instilled into the cervix: there w as no evidence o f endometriosis. Her husband has tw o children from a previous marriage. Pelvic
examination shows a normal-sized uterus and no palpable masses. Postcoital test shows many motile sperm. Which o f the following is the most appropriate pharmacotherapy?

© A) Clomiphene
© B) Danazol
C) Leuprolide
G D) Levothyroxine
© E) Menotropins
© F) Progesterone
Exam Section : item 16 of 50 National Board of Medical Examiners Time Remalnir
■ Mark Obstetrics & Gynecology Self-Assessment__________________________________________________________________4 hr 42 min 24

16. A 37-year-old woman, gravida 2, para 1, at 36 weeks' gestation is admitted to the hospital after she was found to have fetal growth restriction during a routine prenatal visit. She has a 6-year history o f mild
chronic essential hypertension controlled with p-adrenergic blocking agents that were discontinued at 8 weeks' gestation. At 10 weeks' gestation, a 24-hour urine collection shows a protein concentration of
50 mg and creatinine clearance of 110 mL/min. Ultrasonography and amniocentesis at 18 weeks' gestation showed no abnormalities; the estimated fetal weight was at the 50th percentile. Her temperature
today is 36.6'C (97.8° F), pulse is 88/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows a fundal height o f 30 cm. Ultrasonography shows a fetal head circumference
consistent in size with a 35-week gestation and an abdominal circumference consistent in size with a 30-week gestation. The estimated fetal weight is at the 9th percentile. Which o f the following is the most
appropriate test to determine the risk of intrauterine fetal demise?

A) Determination o f nuchal thickness

O B) Fetal fibronectin test
9 C) Glucose tolerance test
9 D) Doppler ultrasonography of the umbilical artery
9 E) Determination o f amniotic fluid glucose concentration
Exam Section : Item 17 of 50 National Board of Medical Examiners Tim# Remaining
■ Obstetrics & Gynecology Self-Assessment 4 hr 41 min 12 s

17. A 32-year-old woman, gravida 3. para 2. comes to the physician for her first prenatal visit. Her last menstrual period was 17 weeks ago. Examination shows a uterine fundus that is palpated midway between
the pubic symphysis and umbilicus. Her serum a-fetoprotein concentration is 2.6 multiples of the median. Which of the following is the most appropriate next step in management?

A) Repeat measurement of serum a-fetoprotein concentration

« B) Serum studies for fetal erythrocytes
S C) Ultrasonography
# D) Amniocentesis
E) Pregnancy termination
Exam Section : Item 18 of SO National Board of Medical Examiners Time Remaining
M Mark Obstetrics & Gynecology Self-Assessment 4 h r 39 min 49 3

18. A 52-year-old woman comes to the physician because of a 6-month history of urinary urgency. She often has a strong urge to void but passes only a small amount of urine. Sometimes, she is unable to reach
a bathroom quickly enough after feeling the sudden need to void. She says she often 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 12 months ago. She is not sexually active. She is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m-. Her temperature is
3 7 .1 X (98.7" F), pulse is 70/min, respirations are 12/min, and blood pressure is 90/50 mm Hg. Pelvic examination shows moderate tenderness and vaginal atrophy. The uterus is normal sized. There are no
vulvar, vaginal, or cervical lesions or adnexal masses. The remainder of the examination, including rectal examination, shows no abnormalities. Test of the stool for occult blood is negative. A wet mount
preparation of vaginal fluid shows numerous leukocytes. Urine culture is negative. Her postvoid residual volume is 50 mL. Which of the following is the most likely underlying cause of these findings?

9 A) Atonic bladder
9 B) Estrogen deficiency
9 C) Prolapse of the pelvic floor
0 D) Trichomoniasis
E) Urinary tract infection
Exam Section : Item 19 of 50 National Board of Medical Examiners
■ Obstetrics & Gynecology Self-Assessment 4 hr 38 m

19. A 23-year-old woman, gravida 3. para 2. at 26 weeks' gestation comes to the physician for a follow-up examination. She reports that her daughter had a flu-like illness 2 months ago that resolved without
medical treatment. Her pregnancy has been otherwise uncomplicated, and results o f prenatal laboratory studies have been within the reference ranges. Examination shows a fundal height of 34 cm.
Ultrasonography shows polyhydramnios, fetal ascites, and skin thickening. Infection with which o f the following is the most likely cause of these findings?

9 A) Adenovirus
9 B) Coxsackievirus A
9 C) Cytomegalovirus
9 D) Herpes simplex virus
9 E) Parvovirus B19
Exam Section : item 20 of 50 National Board of Medical Examiners Time Remaininj
■ Mark_________________ Obstetrics & Gynecology Self-Assessment 4 hr 36 min 13 *

20. A 50-year-old woman, gravida 3. para 2. aborta 1, has had loss of urine with coughing, straining, or lilting since the birth of her last child 9 years ago; the symptom has progressively worsened over the past
2 years. During examination, she loses urine in small spurts with coughing, but the anterior and posterior vaginal walls appear well supported. A cotton-tipped applicator placed in the urethra moves in an arch
of 45 degrees with the horizontal during Valsalva maneuver. Which of the following is the most likely diagnosis?

4 A) Cystocele
4 B) Enterocele
4 C) Femoral hernia
4 D) Fourth-degree obstetric laceration
4 E) Hiatal hernia
4 F) Indirect inguinal hernia
4 G) Rectocele
4 H) Urethrocele
Exam Section : item 21 of 50 National Board of Medical Examiners Tim# Remainii
9 Mark Obstetrics & Gynecology Self-Assessment 4 hr 34 min 21

21. An otherwise healthy 27-year-old woman comes to the physician 2 weeks after noticing a tender mass in her left breast during breast self-examination. She has a history of similar smaller masses that
resolved spontaneously within a few weeks. She feels well and takes no medications. Menses occur at regular 28-day intervals. Her last menstrual period was 3V? weeks ago Vital signs are within normal
limits. There is no lymphadenopathy. The breasts are symmetric, and there are no skin changes. Examination of the left breast shows several 1-cm. smooth, soft, mobile masses and a 3-cm. mobile, soft,
tender mass in the upper outer quadrant. Examination of the right breast shows tenderness to deep palpation and small masses similar to the left breast. Which of the following is the most likely diagnosis?

# A) Abscess
€ B) Fat necrosis
# C) Fibroadenoma
4 D) Fibrocystic changes of the breast
€ ' E) Galactocele
G F) Intraductal papilloma
€> G) Lipoma
H) Mammary ductal ectasia
® I) Mastitis
Exam Section : item 22 of 50 National Board of Medical Examiners 1i" '* 3 maintr
j Marit Obstetrics & Gynecology Self-Assessment 4 Jir3 3 jn in 2 7

22. A 77-year-old woman, gravida 2, para 2, comes to the physician because of a 1-month history of intermittent episodes o f vaginal bleeding. Each episode lasts 3 to 4 days and is not associated with trauma
or sexual intercourse. Menopause occurred 26 years ago. and she has never received hormone therapy. Her last gynecologic examination was 38 years ago following the birth of her youngest child. She
takes no medications. She has smoked tw o packs of cigarettes daily fo r 50 years. Physical examination shows no abnormalities. Pelvic examination shows a 2-cm, exophytic lesion on the cervix. There is no
enlargement of the uterus or evidence of blood in the vagina. Results of a biopsy specimen of the lesion are most likely to show which o f the following?

G A) Adenocarcinoma
B) Carcinosarcoma
® C) Clear cell carcinoma
€ D) Papillary serous carcinoma
€ E) Squamous cell carcinoma
Exam Section : Item 23 of 50 National Board of Medical Examiners Time Remaining
■ Mark Obstetrics & Gynecology Self-Assessment 4 hr 31 min 59 s

23. A previously healthy 42-year-old woman comes to the physician because of irregular menses during the past 7 months. She also has had intense mood changes and occasional hot flashes during this time.
Her last menstrual period was 6 weeks ago. She is sexually active with one male partner, and they usually use barrier contraception. Examination, including pelvic examination, shows no abnormalities. Which
of the following is the most appropriate next step in diagnosis?

# A) Measurement of serum estradiol concentration

€ B) Measurement of serum testosterone concentration
® C) Pregnancy test
€ D) Transvaginal ultrasonography
# E) Endometrial biopsy
Exam Section : Item 23 of 50 National Board of Medical Examiners
j Mark_______________________________________________________________________________ Obstetrics & Gynecology Self-Assessment____________________________________________________________________ (RleaselW ai:

24. A 32-year-old woman, gravida 3. para 2. at 30 weeks' gestation is brought to the emergency department because of pain in the right mid abdomen for 12 hours; she has had one episode of diarrhea since
that time. Her temperature is 38.5"C (101,3‘ F). Physical examination shows diffuse tenderness in the right lower quadrant of the abdomen with minimal guarding. Rectal and pelvic examinations show right­
sided tenderness. Her leukocyte count is 14,000/mm3with a shift to the left. Ultrasonography of the abdomen shows fluid in the right paracolic gutter: the appendix cannot be visualized. Which of the following
is the most appropriate next step in management?

$ A) Cultures of the stool

€ B) Barium enema
® C) Broad-spectrum antibiotic therapy and observation
S D) Sigmoidoscopy
€ E) Surgical exploration
Exam Section : Item 25 of 50 National Board of Medical Examiners
■ Mari, Obstetrics & Gynecology Self-Assessment 4 hr 30 min 4

25. One month after an uncomplicated vaginal delivery o f a 3400-g (7-lb 8-oz) newborn, a 32-year-old woman, gravida 2, para 2, comes to the physician because of a 7-day history of a tender mass in her left
breast. Her pregnancy had been complicated by abdominal trauma sustained in a motor vehicle collision. A second-degree midline vaginal laceration was repaired without difficulty after delivery. She is
breast-feeding. Her temperature is 37°C (9 8 .6 'F). Examination shows a 3 x 3-cm. fluctuant mass in the lateral aspect o f the left breast. The mass is mildly tender to palpation. The breast is not warm or
erythematous. The breasts are symmetric. Which of the following is the most likely diagnosis?

4 A) Abscess
€ B) Breast engorgement
# C) Galactocele
6 D) Mastitis
4 E) Supernumerary breast
Exam Section : Item 26 of SO National Board of Medical Examiners fly
■ Mart, Obstetrics & Gynecology Self-Assessment 4 hr 28 min 6 s

26. A 24-year-old primigravid woman at 42 weeks' gestation is admitted to the hospital for labor induction. Her pregnancy has been uncomplicated. She has no history of serious illness. On admission, her
temperature is 36.9°C (98.5"F), pulse is 64/min. and blood pressure is 130/72 mm Hg. Fetal nonstress testing is reactive. Pelvic examination shows a closed, long, posterior cervix. The amniotic fluid index is
3.2 cm (N =9-31). Which of the following is the most appropriate next step in management?

# A) Discharge home and readmit in 1 week

€ B) Administer betamethasone
® C) Administer a prostaglandin
€ D) Begin amnioinfusion
G E) Perform an immediate cesarean delivery
Exam Section : Item 27 of 50 National Board of Medical Examiners Time Remaining
■ Mori, Obstetrics & Gynecology Self-Assessment 4 hr 27 min 11 s

27. A 32-year-old woman, gravida 2. para 1. at 18 weeks' gestation comes for a routine prenatal visit. Ultrasonography shows a triplet gestation with no abnormalities. All three fetuses have fetal heart tones and
are appropriate in size for gestational age. For which of the following complications is this patient at increased risk?

€ A) Abruptio placentae
€ B) Oligohydramnios
$ C) Placenta previa
€ D) Polyhydramnios
E) Premature labor
Exam Section : item 28 of 50 National Board of Medical Examiners Time Remaining
B Mark____________________________________________________________________________ Obstetrics & GynecologyS e l f - A s s e s s m e n t _______________________________________ 4 hr 26 min 42 s

28. A 37-year-old woman, gravida 7, para 4. aborta 2, at 40 weeks' gestation is admitted to the hospital in labor. Spontaneous rupture of membranes along with severe abdominal pain occurred 4 hours ago. The
pain is constant and sharp, unlike the labor pains of her previous pregnancies. Her pregnancy had been uncomplicated. Her last pregnancy ended in cesarean delivery at term for breech presentation. Her
temperature is 37°C (98.6 ' F). pulse is 80/min, respirations are 17/min, and blood pressure is 122/68 mm Hg. The fundal height is 28 cm. Leopold maneuvers show fetal small parts above the fundus. External
monitoring shows fetal tachycardia with late decelerations and loss of beat-to-beat variability. Which of the following is the most likely diagnosis?

# A) Abruptio placentae
« B) Chorioamnionitis
® C) Placenta previa
6 D) Umbilical cord prolapse
® E) Uterine rupture
Exam Section : item 29 of SO National Board of Medical Examiners Time Rema
■ Mark__________________ Obstetrics & Gynecology Self-Assessment 4 hr 25 min

29. A previously healthy 32-year-old woman comes to the physician because o f a 2-day history of vaginal bleeding and lower abdominal cramps. Her last menstrual period was 7 weeks ago. She is sexually
active with one partner, and they use condoms for contraception consistently. She takes no medications. Her pulse is 90/min, and blood pressure is 100/65 mm Hg. Physical examination shows a soft
abdomen and lower quadrant tenderness. Speculum examination shows moderate vaginal bleeding and a closed cervical os. A pregnancy test is positive. Transvaginal ultrasonography shows a fluid-filled
endometrial cavity and no gestational sac. Her quantitative serum (3-hCG concentration is 2500 mlU/mL. Forty-eight hours later, a second measurement of quantitative serum |3-hCG concentration is
2800 mlU/mL. Which o f the following is the most likely diagnosis?

A) Blighted ovum
4 B) Complete spontaneous abortion
C) Ectopic pregnancy
4 D) Hydatidiform mole
E) Normal intrauterine pregnancy
Exam Section : item 30 of 50 National Board of Medical Examiners Time Remaining
■ Obstetrics & Gynecology Self-Assessment 4 hr 23 min 21 s

30. A 47-year-old woman has had increasing fatigue, constipation, night sweats, anxiety, and mood lability over the past year; she has had a 2.3-kg (5-lb) weight gain during this period. Her last menstrual period
was 6 months ago. Her blood pressure is 130/80 mm Hg. Physical and pelvic examinations show normal findings. Which of the following serum concentrations is most likely to be increased?

A) ACTH
C B) Follicle-stimulating hormone
® C) Parathyroid hormone
# D) Thyroid-stimulating hormone
E) Thyrotropin-releasing hormone
Exam Section : item 31 of 50 National Board of Medical Examiners Time Re mall
■ M ark Obstetrics & Gynecology Self-Assessment 4 hr 21 min

31. A 62-year-old woman comes to the physician because o f tw o episodes o f vaginal bleeding during the past 3 weeks. Menopause occurred 12 years ago. She has hypertension treated with an ACE inhibitor
and type 2 diabetes mellitus treated with oral hypoglycemic agents. She has no history o f abnormal annual Pap smears. She is 163 cm (5 ft 4 in) tall and weighs 66 kg (145 lb); BMI is 25 kg/m 2. Pelvic
examination shows a normal cervix and uterus with blood at the cervical os. A 6 x 8-cm left ovarian mass is palpated. Pelvic ultrasonography confirms the results of physical examination. An endometrial
biopsy specimen shows atypical complex hyperplasia. Which o f the following is the most likely diagnosis?

A A) Brenner tumor
B) Granulosa cell tumor
A C) Ovarian carcinoma
f i D) Ovarian fibroma
€ E) Sertoli-Leydig cell tumor
Exam Section : Item 32 of 50 National Board of Medical Examiners Tim® Re
■ Mori, Obstetrics & Gynecology Self-Assessment 4 hr 19 r

32. A 26-year-old woman, gravida 3. para 2. comes fo r her first prenatal visit at 11 weeks' gestation. Her previous pregnancies and deliveries were uncomplicated. Her blood type is O, Rh-negative. She
received Rht(D) immune globulin after her first delivery. Which of the following is the most appropriate test to evaluate her Rh status?

A) Determination of husband's Rh genotype

$ B) Measurement o f fetal hemoglobin concentration
C) Measurement of serum bilirubin concentration
€ D) Indirect antiglobulin (Coombs) test
E) Kleihauer-Betke acid elution test
Exam Section : item 33 of 50 National Board of Medical Examiners Time Remaining
■ M a rk Obstetrics & Gynecology Self-Assessment 4 hr 18 min 20 s

33. A 21 -year-old woman comes to the physician because of a 2-week history of a small amount of vaginal discharge and itching; her symptoms began immediately before her last menstrual period. She has had
two sexual partners over the past 2 months and uses an oral contraceptive. One month ago, she had pain on urination and urinary frequency that resolved after a 7-day course of cephalexin. Examination
shows a red introitus and vulva. There are erythematous vaginal walls with a normal amount of vaginal discharge. The cervix and cervical discharge are normal. Vaginal pH is 4.5. The addition of KOH to the
discharge produces no odor. A wet mount preparation shows no motile organisms. Which of the following is the most likely causal organism?

# A) Candida albicans
# B) Chlamydia trachomatis
9 C) Gardnerella vaginalis
D) Neisseria gonorrhoeae
E) Trichomonas vaginalis
Exam Section : Item 34 of 50 National Board of Medical Examiners Time Remainir
m Mark Obstetrics & Gynecology Self-Assessment 4 hr 16m in10

34. A 37-year-old woman, gravida 5, para 3, aborta 1, at 40 weeks' gestation is admitted in labor. Contractions began 2 hours ago. She has not had vaginal bleeding or loss o f fluid. Her pregnancy has been
uncomplicated. Her last child was delivered vaginally at term and weighed 4300 g (9 lb 8 oz). At her last prenatal visit 1 week ago, the cervix was 50% effaced and 1 cm dilated, and the vertex was at
- 2 station. Examination now shows contractions that occur every 5 minutes. The cervix is 50% effaced and 6 cm dilated: no presenting part can be felt. A fetal heart tracing shows no abnormalities. Which of
the following is the most appropriate next step in management?

A) Arterial blood gas analysis of the umbilical artery

B) Fetal scalp stimulation
C) Ultrasonography of the pelvis
O' D) Amniotomy
® E) Cesarean delivery
Exam Section : item 35 of 50 National Board of Medical Examiners Time Rer
■ M a rk Obstetrics & Gynecology Self-Assessment 4 hr 15 rr

35. A t 37 w eeks' gestation, a 28-year-old woman with gestational diabetes delivers a 4500-g (10-lb) newborn who develops hyaline membrane disease. The mother had postprandial serum glucose
concentrations of 180-200 mg/dL during the last half of pregnancy. The macrosomia and pulmonary disease are most closely related to an increased serum concentration of which of the following in the
fetus?

® A) Cortisol
B) Growth hormone
S C) Human placental lactogen
S D) Insulin
S E) Reverse triiodothyronine (rT j)
Exam Section : item 36 of 50 National Board of Medical Examiners Time Remain
■ Mark__________________ Obstetrics & Gynecology Self-Assessment 4 hr 9 min 51

36. A 17-year-old girl is brought to the physician by her mother because she has never had a menstrual period. She is otherwise healthy. Both of her older sisters had normal pubertal development. Examination
shows absent breast development and scant pubic hair. Her serum follicle-stimulating hormone concentration is 105 mlU/mL. Which o f the following is the most appropriate next step in diagnosis?

A) Gonadotropin-releasing hormone stimulation test

4 B) Karyotype analysis
C) Measurement of serum electrolyte concentrations
« D) Measurement o f serum luteinizing hormone concentration
E) Measurement of serum thyroid-stimulating hormone concentration
Exam Section : item 37 of 50 National Board of Medical Examiners Time Remaining
■ MgrL Obstetrics & Gynecology Self-Assessment 4 hr 9 min 15 se

37. A 47-year-old nulligravid woman comes to the physician because of heavy menstrual flow during the past 3 months. Previous menses were normal with regard to flow. She has mild hypertension treated with
diuretics and type 2 diabetes mellitus treated with oral hypoglycemics. She has no history of abnormal Pap smears. She is 160 cm (5 ft 3 in) tall and weighs 95 kg (210 lb); BMI is 37 kg/m2. Her blood
pressure is 146/86 mm Hg. Physical examination shows no other abnormalities. A Pap smear is reported as atypical glandular cells. Colposcopy shows no abnormalities. Endocervical curettage shows benign
cells. Which of the following is the most appropriate next step in diagnosis?

9 A) Second Pap smear in 6 months

B) Human papillomavirus testing
$ C) Pelvic ultrasonography
9 D) Endometrial biopsy
4 E) Loop electrosurgical excision of the cervical transformation zone
Exam Section : Item 38 of 50 National Board of Medical Examiners Time Rem
■ M a rk Obstetrics & Gynecology Self-Assessment 4 hr 7 min

38. A 28-year-old woman, gravida 1. para 1. has been amenorrheic and has had hot flashes for the past 6 months. She takes thyroid medication fo r chronic lymphocytic thyroiditis (Hashimoto disease). Alter
using an oral contraceptive for 2 years, she discontinued taking it 3 years ago. Serum studies show:
Follicle-stimulating hormone 62 mlU/mL
Estradiol 15 pg/mL (N=20-60>
Thyroid-stimulating hormone 1.5 pU/mL
Prolactin 5 ng/mL

Which of the following is the most likely cause of this patient's condition?

O A) Autoimmune ovarian failure

B) Hypothalamic dysfunction
® C) Inadequate control o f hypothyroidism
D) Post-pill amenorrhea
O E) Pure gonadal dysgenesis
Exam Section : item 39 of 50 National Board of Medical Examiners Tim e Remaii
* M a r k __________________________ Obstetrics & Gynecology Self-Assessment 4 hr 4 min 1

39. A 27-year-old woman comes to the physician because of painful vulvar swelling fo r 2 days. She has had three episodes of Neisseria gonorrhoeae infection treated successfully with oral antibiotics over the
past 5 years. Examination shows a 4-cm, tender, fluctuant mass of the labium majus. Which o f the following is the most likely diagnosis?

# A) Bacterial vaginosis
€ B) Bartholin duct abscess
® C) Human papillomavirus infection
€ D) Lichen sclerosus
E) Urethral diverticulum
F) Vulvar vestibulitis
txam Section : item 40 of 50 National Board of Medical Examiners Time Remainin
B M a rk Obstetrics & Gynecology Self-Assessment 4 hr 3 min 31 s

40. A 20-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in labor. She reports severe abdominal pain. She has received no prenatal care. She has no history of serious
illness and takes no medications. Leopold maneuvers indicate a fetus at term. The cervix is 10 cm dilated and 100% effaced; the vertex is at +2 station. After pushing for 3 hours, low-forceps-assisted
delivery is performed because of nonreassuring fetal heart tones, severe variable decelerations, and maternal exhaustion. The operative vaginal delivery of a 4200-g (9.3-lb) newborn is complicated by
shoulder dystocia that requires 8 minutes to reduce. On examination, the newborn does not move the right arm. The forearm is pronated, and the arm is adducted and internally rotated at the shoulder, Which
of the following is the most likely cause of these findings in this newborn?

O A) Fracture of the clavicle

6 B) Hypoxic injury to the motor area of the precentral gyrus
C) Injury to the eighth cervical root and first thoracic root
4 D) Injury to the fifth and sixth cervical roots
€ E) Partial dislocation of the elbow
Exam Section : Item 40 of 50 National Board of Medical Examiners
■ Marti__________________ Obstetrics & Gynecology Self-Assessment

41. A 38-year-old woman, gravida 3. para 1. aborta 1. is admitted to the hospital at 33 weeks' gestation because of suspected pyelonephritis as evidenced by temperatures to 38.9"C (102” F) and back pain. She
has had costovertebral angle tenderness for 10 days and mild contractions for 4 hours. Intravenous ampicillin therapy is started. Urinalysis is consistent with a urinary tract infection. The fetal heart rate
pattern is shown. Which of the following is the most likely explanation for this pattern?

A) Fetal hypoxia
# B) Maternal age
C) Maternal fever
# D) Preterm gestation
E) Reaction to antibiotics
Exam Section : Item 42 of 50 National Board of Medical Examiners Time Remaminj
B Mart,______________________________________________________________________________ Obstetrics & Gynecology Self-Assessment__________________________________________________________________ 4 hr 1 min 8 sei

42. A 37-year-old woman, gravida 1, para 1. with recently diagnosed breast cancer comes to the physician for advice regarding contraception. She will begin chemotherapy and radiation therapy in 6 weeks. She
had been using a combination oral contraceptive for 3 years but discontinued it 8 weeks ago on advice of her oncologist and began using condoms. Since discontinuing oral contraceptive therapy, she has had
one menstrual period that lasted 4 days. Previously, menses occurred at regular 28-day intervals and lasted 3 to 4 days. She delivered her first child 18 months ago and wishes to have another child in the
future. She has no other history of serious illness and takes no other medications. Her blood pressure is 115/72 mm Hg. Pelvic examination shows no abnormalities. Which of the following is the most
appropriate recommendation regarding contraception for this patient?

A) Progestin-only oral contraceptive

€ B) Diaphragm
® C) Placement of a copper IUD
® D) Depot medroxyprogesterone
E) Etonogestrel implant
Exam Section : Item 43 of 50 National Board of Medical Examiners Time Remaining:
B Mark_______________________________________________________________________________Obstetrics & Gynecology Self-Assessment_________________________________________________________________3 hr 59 min 23 si

43. A 35-year-old woman, gravida 2. para 1. with chronic hypertension has spontaneous onset of labor at 39 weeks' gestation. After 4 hours of regular contractions and a second stage of 5 minutes, she
spontaneously delivers a 3650-g (8-lb 1-oz) newborn under epidural anesthesia. Approximately 2 minutes after separation of the placenta, she develops apnea, cyanosis, and severe hypotension. During the
unsuccessful resuscitation, the patient develops bleeding from the vagina and venipuncture sites. Which of the following is the most likely diagnosis?

# A) Amniotic fluid embolism

€ B) Aspiration
# C) Cerebral infarction
€ D) Myocardial infarction
€ E) Septic shock
Exam Section : Item 44 of 50 National Board of Medical Examiners Time Remalnini
■ Obstetrics & Gynecology Self-Assessment 3 hr 58 min 18 :

44. A 47-year-old woman comes to the physician for a follow-up examination. Six weeks ago, she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for leiomyomata uteri. She has
no history of abnormal Pap smears. Examination today shows a well-healing incision. Which of the following is the most appropriate next step regarding future Pap smears for this patient?

G A) Annually
$ B) Annually for 3 years and then every 3 years
€> C) Every 3 years
€ D) In 1 year and then no longer indicated
# E) No longer indicated
Exam Section : Item 45 of 50 National Board of Medical Examiners vTI|Aa;RMrt
■ Mart, Obstetrics & Gynecology Self-Assessment 3 hr 57 mi

45. A 26-year-old nulligravid woman has had infertility for 2 years. Menses occur at regular 25-day intervals. Serum progesterone concentration is 8 ng/mL (N>5) on menstrual day 21. An endometrial biopsy
specimen on menstrual day 24 is most likely to show which of the following in this patient?

A) Atrophic endometrium
€ B) Decidual endometrium
* C) Hyperplasia of endometrium
€ D) Proliferative endometrium
E) Secretory endometrium
Exam Section : Item 46 of 50 National Board of Medical Examiners Time Remaining
■ Marb Obstetrics & Gynecology Self-Assessment 3 hr 56 min 5 sc

46. A 37-year-old primigravid woman at 31 weeks' gestation comes to the physician for a routine prenatal visit. She reports a 4-day history of mild difficulty breathing, especially when in the reclining position. She
has no history of serious illness; her only medication is a prenatal vitamin. Her temperature is 37“ C (98.6” F). pulse is 90/min, respirations are 18/min. and blood pressure is 130/80 mm Hg. The fundal height
is 37 cm. Pelvic examination shows no cervical dilation or effacement. Ultrasonography shows a normal-appearing fetus. The amniotic fluid index is 35 cm (N=10-20). Which of the following is the most
appropriate next step in management?

# A) Complete bed rest until delivery

B) Recommendation to limit dietary sodium intake
C) Antenatal testing
S ’ D) Diuretic therapy
C E) Weekly amniocentesis for removal of fluid
Exam Section : item 47 of 50 National Board of Medical Examiners Time Remi
■ Obstetrics & Gynecology Self-Assessment 3 hr 53 mil

47. A 22-year-old primigravid woman at 24 w eeks' gestation has had fullness in the lower pelvic area for 12 hours. She has no contractions. Fundal height is 20 cm. Fetal heart tones are good. Examination
shows the fetus in a breech presentation in the vagina. No cervix is palpated. Which of the following is the most likely diagnosis?

A) Abruptio placentae
$ B) Cervical carcinoma
$ C) Incompetent cervix
# D) Placenta previa
% E) Premature labor
® F) Premature rupture o f the membranes
® G ) Prolapsed cord
• H) Vaginal varicose veins
® I) Normal labor
Exam Section : Item 48 of SO National Board of Medical Examiners Time Remain
j Mark________________________________________________________________________________Obstetrics & Gynecology Self-Assessment__________________________________________________________________ 3 h r 52 min 2

48. A 27-year-old woman, gravida 2, para 1. at 30 weeks' gestation comes to the physician because of chronic fatigue for 2 months; she has had a 4.5-kg (10-lb) weight loss during this period. She has had no
prenatal care. She has a history of alcoholism and drug abuse. She is 168 cm (5 ft 6 in) tall and weighs 59 kg (130 lb); BMI is 21 kg/m-. She appears chronically ill. Examination shows pallor. The uterine
fundal height is 28 cm. The fetal heart rate is 140/min. Laboratory studies show:
Hemoglobin 6.0 g/dL
Mean corpuscular hemoglobin 30 pg/cell
Mean corpuscular volume 101 pm3
Leukocyte count ASOO/mm’
Reticulocyte count 0.1%
Platelet count 130,000/mm3
Prothrombin time 13 sec
Serum
Bilirubin (total) 1.0 mg/dL
ALT 16U /L

Which of the following is the most likely cause o f this patient's anemia?

A) Bone m arrow hypoplasia

0 B) Cirrhosis
® C) Folic acid deficiency
0 0 ) Hepatitis
© E) Iron deficiency
F) Vitamin B ,2(cobalamin) deficiency
Exam Section : National Board of Medical Examiners Time Remaining
■ M a rk ________ Obstetrics & Gynecology Self-Assessment 3 hr 51 min 19 s

49. A 19-year-old primigravid woman comes to the emergency department because of a 1-week history of nausea and persistent vomiting. Her last menstrual period was 15 weeks ago. but she has had daily
vaginal bleeding for the past month. She has not received prenatal care. Her temperature is 37”C (98.6"F), pulse is 80/min, respirations are 20/min, and blood pressure is 140/90 mm Hg. Examination shows
pedal edema. Pelvic examination shows a uterus consistent in size with a 20-week gestation: there is no adnexal tenderness. A serum pregnancy test is positive. Urinalysis shows 1+ protein. Ultrasonography
shows bilateral multilocular ovarian cysts and echogenic structures in the uterus. Which of the following is the most likely diagnosis?

4 ' A) Combined ectopic and intrauterine pregnancy

€ B) Hydatidiform mole
€> C) Multiple gestation
# D) Ovarian hyperstimulation syndrome
S' E) Placenta accreta
S> F) Polyhydramnios
Exam Section : item 50 of 50 National Board of Medical Examiners Time Remaining
■ Mgri, Obstetrics & Gynecology Self-Assessment 3 hr 50 min 24 s

50. A sexually active 21-year-old college student requests an oral contraceptive. There are no contraindications based on her medical history. In addition to a Pap smear, which of the following screening tests is
most appropriate?

A) Test for Chlamydia trachomatis

B) Liver function tests
C) Measurement of fasting serum glucose concentration
4 D) Assay for serum HIV antibodies
C E) Serologic test for syphilis