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Questions 1 and 2 refer to the following case.
A 26-year-old woman presents to the emergency department (ED) complaining of vaginal bleeding and abdominal pain. She states that the pain began today and has been getting progressively worse. Her last menstrual period was 7 weeks ago. On physical examination, she appears uncomfortable. She is afebrile, and blood pressure is 108/76 mm Hg, heart rate is 58 bpm, and respiratory rate is 18 breaths/min. Abdomen is soft with mild diffuse tenderness. Pelvic examination reveals a small amount of blood oozing from the cervical os. The uterus is slightly enlarged but nontender with no adnexal masses..
1. Which of the following is the most appropriate initial step in the management of this patient?
- Administer RhoGam 50 μg
- Obtain a urine β-human chorionic gonadotropin (β-hCG) measurement
- Order a rapid hematocrit
- Perform a type and screen
- Perform a urinalysis
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2. The emergency medicine physician performs a bed-side endovaginal ultrasound on this patient (Figure). Based on these results, what is the most appropriate next step?
- Administer methotrexate 50 mg/m²
- Administer RhoGam 300 μg
- Dilation and curettage
- Laparoscopic surgery
- Order a formal pelvic ultrasound
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3. A 26-year-old gravida 6, para 5 women at 36 weeks of gestation arrives in the ED via ambulance and precipitously delivers a male child. The child coughs and has a strong cry. He is very active. Acrocyanosis is noted. Heart rate is 98 bpm and breathing is strong. What is the child’s Apgar score?
- 5
- 6
- 7
- 8
- 9
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Figure. Endovaginal ultrasound performed in the patient described in questions 1 and 2.
4. A 24-year-old pregnant woman at 29 weeks of gestation presents to the ED after being assaulted by her husband. She is in full cervical spine precautions. She complains of abdominal pain that began immediately after she was hit in the abdomen. On physical examination, the patient is tearful and in obvious discomfort. The patient is afebrile, and blood pressure is 80/55 mm Hg, heart rate is 100 bpm, and respiratory rate is 20 breaths/min. She has multiple occipital hematomas and facial ecchymosis. Pupils are equal and reactive bilaterally. The neck is nontender without bony deformity. Lungs are clear to auscultation. Heart rhythm is regular. The abdomen is gravid, and the uterine fundus measures 29 cm. Fetal heart tones are 160 bpm. There is no vaginal bleeding or discharge. What is the initial step in the management of this patient?
- Begin cardiotocographic monitoring
- Establish central venous access
- Intubate the patient
- Perform a pelvic speculum examination
- Reposition the patient
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5. Which of the following conditions is associated with blunt trauma in a pregnant woman?
- Abruptio placentae
- Fetal malformation
- Placenta accreta
- Placenta previa
- Premature rupture of membranes
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