21. To minimize the risk of aspiration and resultant pneumonitis,
A. Place patient in left-uterine displacement
-receptor antagonist to decrease the pH of gastric fluid present in the
C. Give metoclopramide to reverse opioid-induced gastric hypomotility
D. Give a nonparticulate antacid to decrease the pH of the gastric fluid
22. The most common cause of late decelerations in fetal heart rate (FHR) (down to 90
B. Compression of the fetal head
23. After performing a single-shot intrathecal anesthetic consisting of 7.5 mg of
preservative-free bupivacaine and 25 μg of fentanyl, the surgical incision is made
and systemic hypotension (78/44 mm Hg) ensued. To avoid significant decreases in
uterine blood flow, first-line therapy to consider is
A. Provide additional inhaled nitric oxide (NO) to vasodilate the uterine
B. Increase maternal cardiac output with use of epinephrine
C. Increase intravascular volume with fluids
D. Use reverse Trendelenburg to decrease aortocaval compression
With increasing concern of variable decelerations, a male fetus is delivered with vacuum
assistance. The amniotic fluid was noted to be meconium stained. Initial evaluation reveals
a cyanotic limp infant with a heart rate of 80 bpm, poor respiratory efforts, and grimacing in
24. Patient’s Apgar score would be
25. Appropriate initial steps in the resuscitation efforts would include all of the
B. Provide radiant heat source
C. Positive-pressure ventilation
26. Regarding forceps-assisted delivery
A. High-forceps delivery has the highest success rate
B. Prevents clavicle fracture associated with dystocia
C. Hastens postpartum maternal recovery
D. Is associated with increased incidence of fetal facial nerve trauma
27. True statement regarding fetal circulation includes
A. The ductus venosus shunts blood away from the pulmonary circuit.
B. Deoxygenated blood is carried in the umbilical vein.
C. The foramen ovale shunts blood from right to left ventricles.
D. Intracardiac pressures are equalized across both right and left ventricles.
28. Successful transition from fetal to neonatal circulation is required after birth to
support extrauterine life. This depends primarily on these factors, except
B. Decreased systemic vascular resistance
C. Decreased pulmonary vascular resistance
D. Closure of the intra- and extracardiac shunts
29. In considering placental exchange and fetal uptake, all statements are true, except
A. Minimizing the maternal blood concentrations of a drug is the most important
method of limiting the amount that ultimately reaches the fetus
B. Drugs that readily cross the blood–brain barrier will also cross the placenta
C. Placental exchange of substance occurs principally via ion transport from the
maternal circulation to the fetus
D. Ion trapping explains why fetal-to-maternal lidocaine ratios are higher during
fetal acidemia than during normal fetal well-being
30. Which of the following best explains why lidocaine has a higher fetal-to-maternal
plasma ratio when compared with bupivacaine?
A. Bupivacaine has a smaller molecular weight
B. Lidocaine has higher protein-binding
C. Bupivacaine has a lower dissociation constant (pKa
D. Lidocaine is less lipid soluble
31. In order to provide analgesia for all stages of labor, one must accommodate the
evolving and varied course of labor and delivery. The least accurate statement
regarding the anatomy of labor is
A. Pain during labor and delivery is often described in two stages
B. Somatic and visceral innervation of the uterus and cervix enters the spinal cord
C. Innervation of the perineum is primarily via the pudendal nerve
D. Somatic and visceral afferent sensory fibers from the uterus and cervix travel
with greater, lesser, and least splanchnic nerves via the celiac plexus
32. The regional or neuraxial technique that would not be expected to provide
appropriate analgesic benefit during the first stage of labor is
A 37-year-old G9P4 patient at 38 weeks of gestation presents for management of labor and
delivery. She denies any medical history and admits to minimal prenatal care. The patient
is moderately hypertensive (160/95) with associated pitting edema at her ankles.
33. The statement about her disorder that is most likely true is
B. Preeclampsia is a syndrome manifested after the 36th week of gestation
C. HELLP syndrome is the mildest form of eclampsia
D. Definitive treatment of preeclampsia is delivery of the fetus and placenta
34. The patient is started on oxytocin to augment her labor, and the patient is now
requesting a labor epidural. Anesthetic considerations include
A. The presence of hypertension and edema requires further workup before
B. No workup is required prior to performing epidural anesthesia, as this will treat
C. Neuraxial anesthesia should be avoided, as there is increased risk of bleeding
D. Avoid systemic opiates, as the risk of respiratory depression is too high
35. After a review of her laboratory results, a lumbar (L3–L4) epidural was placed
without incident (including lack of CSF, and negative test dose after administration
of 45 mg lidocaine with 1:200,000 epinephrine). Epidural anesthesia is then initiated
with a bolus of 15 mg of bupivacaine. Variable decelerations are noted minutes later
on fetal heart rate monitoring. If scalp pH reveals fetal acidosis, compared with a
normal pH, the anesthetic absorbed by the fetus will be present in
A. Higher concentration, most in ionized form
B. Lower concentration, most in ionized form
C. Higher concentration, most in unionized form
D. Unchanged concentration, equal fraction of ionized and nonionized
36. The patient has now been receiving a dilute infusion (bupivacaine 0.125% with 2
μg/mL fentanyl) for the past 3 hours and reports good pain relief with a bilateral T5
sensory level. Her blood pressure is now 85/45 mm Hg, and her heart rate is 120
bpm. The fetal heart rate pattern begins to show late decelerations. The most
appropriate management in this patient includes
A. Immediate bedside cesarean delivery
B. Administration of phenylephrine
C. Administration of ephedrine
D. Discontinuation of the epidural infusion
37. As augmentation of labor continues, patient’s blood pressure slowly climbs again,
with waning epidural analgesic benefit. Highest pressure was noted to be 166/112
mm Hg with heart rate sustained over 100 bpm. The most appropriate pharmacologic
option for acute treatment of severe hypertension in a preeclamptic patient is
38. Four hours postdelivery, and after the epidural is removed, the patient now requires
emergent anesthesia for surgical removal of retained placental products. The
appropriate anesthetic management includes all of the following, except
B. Total intravenous anesthesia
C. General endotracheal inhaled anesthetic
39. Forty-eight hours postdelivery, the patient is febrile, complaining of chills with
severe occipital and neck pain worsened with sitting and standing, but not improved
when lying in bed. The finding you would not expect to find on examination is
D. Normal white blood cell (WBC) count
40. Postdural puncture headache (PDPH) occurs more frequently
A. In elderly (>50 year old) vs. young patients
B. In underweight vs. overweight patients
C. With a cutting-point vs. pencil-point spinal needles
D. With larger- vs. smaller-gauge spinal needles
41. Decrease in fasciculations can be seen following induction doses of succinylcholine
for emergent cesarean section. The factor that can blunt this response is
B. Prior magnesium administration
C. Prior nitrous oxide inhalation
42. Administration of all the following will provide uterine relaxation, except
43. Adverse effects of inhaled β-tocolytic therapy for preterm labor to the mother
include all of the following, except
44. During a general anesthetic for emergent cesarean section, administering of all of the
following could contribute to increased operative blood loss, except
45. With regard to sodium thiopental, the following statements are accurate, except
A. Peak concentration in the brain occurs at 1 minute postinjection
B. Rapid redistribution allows for return of consciousness in <10 minutes
C. Infusions maintain appropriate surgical conditions with fast recovery due to
D. Repeating the induction dose results in fetal depression
46. The following statements are true regarding umbilical cord blood, except
A. Provides a picture of the acid–base balance in the infant at the moment of birth
B. Double clamping of the umbilical cord at birth will preserve a segment of cord
blood in isolation, which can remain stable for up to 24 hours
C. Cord blood that is still in continuity with the placenta will have shifting acid–
base balance due to ongoing placental metabolism and gas exchange
D. Normal paired arterial and venous specimens can provide evidence against an
intrapartum hypoxic–ischemic event to the newborn
47. Maternally administered drugs that decrease beat-to-beat variability of fetal heart
rate include all of the following, except
48. A 24-year-old G4P2 parturient is undergoing a general anesthetic for emergency
cesarean section due to uterine rupture. All these findings would suggest an amniotic
4 weeks’ gestation is undergoing intracranial clipping of a
large arteriovenous malformation, following sudden onset of a severe headache with
associated nausea/vomiting. Patient is intubated in the interventional radiology suite
and ventilated with settings of TV = 500 mL, respiratory rate = 14 bpm, PEEP = 5
cm H2O, and FIO2 = 1.0. Arterial blood gas (ABG) 30 minutes later reveals pH =
7.55, PaO2 = 502, PaCO2 = 19, and HCO3 = 21. These findings are associated with
A. Decreased fetal cerebral oxygen delivery
B. Decreased placental transfer of oxygen
C. Rightward shift of the oxygen dissociation curve
D. Decreased umbilical blood flow
50. True statement concerning hyperglycemia during pregnancy is
A. Increases risk of fetal microsomia
B. Fetal oxygen requirements remain decreased
C. May contribute to neonatal hypoglycemia
D. Increases risk of sepsis during cesarean delivery
51. True statement regarding neuraxial opioids for labor and delivery is
A. Opioids should never be used as a sole agent
B. Most common side effect is fetal bradycardia
C. Intrathecal morphine is associated with quick peak in concentration and early
onset maternal respiratory depression
D. Systemic absorption is similar to intramuscular (IM) administration
52. All of the following drugs readily cross the placenta, except
53. Following a 0.6 mg/kg intravenous dose of rocuronium to facilitate rapid-sequence
induction in a parturient requiring surgical delivery, one would expect
A. Minimal placental transfer of rocuronium to the newborn
B. Shorter duration of relaxation with concurrent magnesium administration
C. Unsuitable intubating conditions as recommended doses are 1.5 mg/kg
D. Use of rocuronium has been shown to affect Apgar scores and fetal muscle tone
at birth and should be strictly avoided
54. During cesarean section under general endotracheal anesthesia, venous air embolism
A. Is associated with high end-tidal CO2
B. Should be treated with nitrous oxide
C. Is associated with expired nitrogen
D. Induces severe hypertension
A 30-year-old otherwise-healthy G2P0
(167 cm, 68 kg) presents at 34
with the rupture of membranes, single footling in breech presentation with fetal
bradycardia. The decision for emergent cesarean delivery under general anesthesia is
made, and the patient is quickly prepared for a rapid sequence induction. However,
patient’s larynx is noted to be very anterior, and is unable to be intubated after multiple
55. The appropriate next step considering persistent fetal bradycardia (<80 bpm) is
A. Administer 1 mg/kg of rocuronium intravenously
B. Use bag-mask ventilation and allow surgical delivery to proceed
C. Wake the patient up for awake fiberoptic intubation
D. Reposition the patient in Trendelenburg with left-uterine displacement
56. The fetus is quickly delivered (skin-to-skin time of 18 minutes). However, 10
minutes after delivery, her uterus is noted to be boggy and bleeding persists. The
appropriate treatment option is
A. Bolus oxytocin (Pitocin) 20 U intravenously
B. Bolus methylergonovine (Methergine) 0.2 mg intravenously
C. Misoprostol (Cytotec) 800 mg intramuscularly
(Hemabate) 0.25 mg intramuscularly
57. Two hours later, the patient remains apneic and intubated in the intensive care unit.
She is sedated and mechanically ventilated (TV = 450, RR = 12, FIO2 = 0.4) with the
arterial blood gas revealing a pH of 7.45, PaO2 of 100 mm Hg, and PaCO2 of 37 mm
Hg with a base excess of zero. Her examination reveals absent deep-tendon reflexes
throughout. ECG reveals intermittent ventricular bigeminy. This situation could be
58. At 3 weeks’ postpartum, the patient has absence of lactation and denies return of her
menstrual cycle. Review of systems is positive for intolerance to cold, constipation,
hair loss, and 2-pound weight gain. The best explanation for this constellation of
A. Amenorrhea–galactorrhea syndrome
1. D. Increasing levels of progesterone along with an enlarging uterus contributes to
incompetence of the lower esophageal sphincter placing parturients at increased risk
of aspiration. This risk increases further as delayed gastric emptying is associated
with both the onset of labor (sympathetic effects) and μ-opioid administration for
analgesia. Aspiration precautions must be utilized when providing anesthesia for
2. B. During pregnancy, cardiovascular changes include increase in blood volume,
plasma volume, cardiac output, stroke volume, and heart rate. Despite these
increases, the systemic blood pressure, during a normal uncomplicated pregnancy,
does not increase due to decrease in systemic vascular resistance. Similarly, there is
no change in central venous pressures despite the increase in plasma volume due to
increase in venous capacitance (Table 17-1).
Table 17-1 Normal Hemodynamic Changes during Pregnancy
Blood volume Increase of 50% Increase
Heart rate Increase of 10–15 bpm Increase
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