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4c5b320b-023d-54aa-9b23-14ce311e6a6d
Of the following syndromes, which one typically causes cognitive impairment, skeletal abnormalities, short stature, cardiac disease, and restrictive lung disease and is considered to present one of the greatest airway challenges in pediatric anesthesia because of the progressive craniofacial anomalies that can make both intubation and mask ventilation extremely challenging?
Beckwith-Wiedemann syndrome
Angelman syndrome
Treacher-Collins syndrome
Hurler syndrome
5
D
1
Trisomy 21
null
null
null
null
9b6fd654-97e2-52e3-92b5-e721cbdc63eb
Which of the following is the most common type of tracheoesophageal fistula (TEF) seen in neonates?
Esophageal atresia with a blind esophageal pouch and a distal TEF
TEF in the absence of esophageal atresia
Proximal TEF with proximal esophageal pouch ending distal to the fistula
Esophageal atresia with 2 TEFs, one each between the proximal and distal esophagus and the trachea
4
A
1
null
null
null
null
null
4130d7ce-7d15-596d-91b1-8ae4303cbcf4
Which of the following scenarios would be least appropriate for a parentpresent induction of anesthesia?
An anxious 4-year-old girl here for tonsillectomy with her mother, who is tearful but cooperative
A crying 7-year-old for unilateral orchiopexy here with his father, who states he prefers to be with his son when he goes to sleep
A 5-month-old girl for diagnostic MRI under general anesthesia here with her mother, who is an anesthesiologist
A 17-year-old boy with Down syndrome for general anesthesia in the cardiac catheterization suite here with his mother, who attends all of his medical appointments
4
C
2
null
null
null
null
null
b7013e2b-f325-5bba-8afe-7bc4ff9767e7
A woman who has received little prenatal care presents in labor with a frank breech fetus. Fetal age is estimated by ultrasonography to be 33 weeks. Her labor proves unstoppable and she undergoes an emergency cesarean delivery. A live-born, 2-kg female infant is delivered. Shortly after the birth, the infant is noted to have grunting, nasal flaring, and retractions. Cardiac examination is within normal limits. There are no structural abnormalities noted, and oral secretions are of the usual amount. Which of the following radiologic findings is/are most likely on chest X-ray of this infant?
Lung hyperinflation with diaphragmatic flattening and layering of fluid in horizontal lung fissures
Diffuse ground-glass opacities and reduced lung volumes
Loops of bowel in the left thorax with mediastinal shift to the right
Right-sided pneumothorax
5
B
2
Pulmonary edema
null
null
null
null
144a7b6c-681b-53fc-9e0c-322a3a5ad396
43. An 8-year-old, 45-kg girl with severe obstructive sleep apnea (OSA) presents for tonsillectomy and adenoidectomy. She has an uneventful inhalational induction and is intubated after IV placement and administration of propofol, rocuronium, and 50 µg of fentanyl. Intraoperatively, she receives 500 mg of IV Tylenol and 2 mg of IV morphine. At the end of her procedure she is extubated uneventfully and brought to the recovery room. Approximately 2 hours later, she begins to complain of pain. Which of the following is the most appropriate analgesic choice for her?
500 mg of PO Tylenol elixir
30 mg of IV ketorolac
25 µg of IV fentanyl
5 mg of IV morphine
5
C
3
1 mg of IV hydromorphone
null
null
null
null
48a280c8-2eee-5fbc-8bd6-c89e1f015212
The P50 of fetal hemoglobin is which of the following?
15
20
27
32
4
B
1
null
null
null
null
null
b12a7975-b8f8-5652-92ba-c07fb0f3f37c
With regard to the fetal circulatory system, which of the following sites will possess the most oxygenated blood?
The inferior vena cava (IVC)
The superior vena cava (SVC)
The right atrium
The left atrium
5
A
1
The aorta
null
null
null
null
71beac74-7b21-5388-a3e4-de91dc989cb5
A 6-year-old girl who has been diagnosed with a Wilms tumor presents to the OR for resection. You obtain consent from the parents for epidural placement to aid with postoperative analgesia. The safest technique for placement of a thoracic epidural in this age group is which of the following?
Awake with minimal sedation, in the seated position, using the paramedian approach
Under general anesthesia, in the right lateral decubitus position, using the paramedian approach
Awake with moderate sedation, in the seated position, using the midline approach
Under general anesthesia, in the right lateral decubitus position, using the midline approach
4
D
2
null
null
null
null
null
a8518751-83e6-551d-b350-f0ba02a28dea
A 10-year-old, 40-kg boy is involved in a motor vehicle accident along with his parents. He is transported by ambulance to the emergency department after intubation in the field for decreased level of consciousness and hypotension. He is found in the emergency department to have a rigid abdomen concerning for intra-abdominal hemorrhage and is brought emergently to the OR for exploratory laparotomy. His father, who was injured minorly in the crash, accompanies him to the preoperative area and says to you as you take the patient into the OR, "We are Jehovah's Witnesses. He is not to receive blood transfusions." During the case, the patient is hypotensive with BP 60/30, HR 130, and SpO2 94%. Upon entry to the abdomen, 500 mL of frank blood is appreciated. An arterial blood gas is obtained, which shows a hematocrit of 20% with ongoing blood loss. The most appropriate course of action in this case is which of the following?
Begin fluid resuscitation with nonblood products, including crystalloid and nonhuman colloid.
Call the hospital lawyer to obtain an emergency court order to transfuse blood.
Consult the hospital Ethics Committee.
Transfuse blood.
5
D
3
Ask a colleague to go discuss with the parents that without permitting blood transfusion, their child will die.
null
null
null
null
662bb979-77eb-526d-bbfc-ddcd49ecf918
48. Differences in required dosing of propofol between children and adults can be attributed to which of the following?
Increased clearance of propofol in children
Larger volume of distribution in children
More rapid redistribution of propofol from vessel-rich organs in children
A and B
5
E
1
B and C
null
null
null
null
73f23b78-cfb9-5324-941a-92f54cdeffcd
Dexmedetomidine can be safely used in children for all of the following situations EXCEPT which one?
Prevention of emergence delirium
Treatment of opioid withdrawal
As an analgesic adjunct
Induction of general anesthesia with a loading dose of 2-4 μg/kg over 10 minutes
5
D
1
Procedural sedation
null
null
null
null
7bfb30ac-f0bf-5059-8c90-dc6bafd2cf29
When administering sedation outside the OR, which of the following corresponds to a plane of moderate sedation?
Normal response to verbal stimuli; patent-unassisted airway
Responsive to touch or verbal stimuli; may require assistance to maintain patency of airway
Responsive to touch or verbal stimuli; patent-unassisted airway
Purposeful response to painful stimuli but not verbal stimuli; patent-unassisted airway
5
C
1
No response to painful stimuli; requires assistance to maintain patency of airway
null
null
null
null
91c3ad56-2e52-5d63-bd22-550f81b7a339
Which of the following cardiovascular parameters increases with pregnancy?
Left ventricular end-systolic volume
Left ventricular end-diastolic volume
Central venous pressure
Pulmonary artery diastolic pressure
5
B
1
Pulmonary vascular resistance
null
null
null
null
143a02dc-cd1d-5715-a192-3b15e40e178b
Which of the following is NOT consistent with supine hypotensive syndrome of pregnancy?
Bradycardia
Decreased right atrial filling pressure
Normal blood flow in the upper extremities
Increased femoral vein velocity
4
D
1
null
null
null
null
null
0290ee29-306e-5a3b-9173-3f1283858a16
Which of the following characteristics of local anesthetic administration for spinal anesthesia is more common in a parturient than in a nonpregnant patient?
Increased dose requirement for the same level and duration of block
Slower onset of neuraxial blockade
Longer duration of neuraxial blockade
Decreased neural sensitivity to local anesthetics
5
C
1
Increased risk of local anesthetic systemic toxicity
null
null
null
null
8c0dd17f-a6e3-51f2-86cd-70b33645dc3c
Which of the following pharmacokinetic physiologic changes in drug metabolism do you anticipate in a pregnant woman at term?
Decreased requirement of isoflurane for maintenance of general anesthesia
Slower increase in alveolar concentration of inhaled anesthetics due to increased cardiac output
Increased susceptibility to propofol induction
Prolonged paralysis after succinylcholine administration
5
A
1
Increased dose requirements for aminosteroidal neuromuscular blockers (such as vecuronium and rocuronium)
null
null
null
null
d1f29e72-3289-5223-be22-2de8478b5d44
5. During which time period of a normal pregnancy does the PaCO2 decrease to reach a level of 30 mm Hg?
8 weeks
12 weeks
20 weeks
28 weeks
4
B
1
null
null
null
null
null
7fce1074-8403-54d0-8f60-f7ff60fc47a8
Which of the following changes in lung volume occurs in a pregnant patient at term compared with prepregnancy?
Increased functional residual capacity (FRC)
Increased vital capacity
Decreased inspiratory capacity
Decreased expiratory reserve volume
5
D
1
Decreased inspiratory reserve volume
null
null
null
null
f39189cf-a820-55b8-a922-a13f4b69a915
Which of the following renal physiologic adaptations is NOT commonly seen in pregnancy?
Increased creatinine clearance
Increased glomerular filtration rate
Increased protein excretion
Decreased serum bicarbonate
5
E
1
Decreased glucose excretion
null
null
null
null
cb25967b-3c34-50d3-be34-8524b8e04dc0
Which of the following statements is correct regarding biliary disease during pregnancy?
Hormonal changes in pregnancy account for altered bile acid content.
Alkaline phosphatase (AP) levels increase during pregnancy because of biliary stasis.
Intrahepatic cholestasis of pregnancy is a normal phenomenon that is not associated with increased risk to the fetus.
Computerized tomography is the gold standard for diagnosis of gallstones in pregnancy.
5
A
1
Laparoscopic surgery is significantly safer during pregnancy in reducing fetal loss as compared with open cholecystectomy.
null
null
null
null
aaf2856d-cc60-519c-92f8-cc4de2aa2ebc
Which of the following statements regarding gastrointestinal (GI) changes during pregnancy is true?
Gastroesophageal reflux disease is common, and lower esophageal sphincter pressures are significantly reduced during the first trimester.
Gastric emptying becomes progressively more delayed during the later trimesters of pregnancy.
Preoperative fasting guidelines for scheduled cesarean section required increased fasting periods compared with other surgical procedures.
Intestinal transit and peristalsis are slowed during pregnancy, resulting in constipation.
5
D
1
The use of nonparticulate antacids to increase gastric pH has demonstrated a significant decrease in clinical aspiration events.
null
null
null
null
ff3e02be-95fb-5aa6-81bf-538f17c8b71f
Which of the following statements regarding hematologic changes during pregnancy is false?
Plasma volume increases more in pregnancy than red blood cell (RBC) volume, resulting in a physiologic anemia of pregnancy.
There is increased fibrinolytic activity during pregnancy, resulting in elevated fibrin degradation products.
Procoagulant proteins including factors I, VII, VIII, IX, and X are increased during pregnancy, resulting in a prothrombotic state.
White blood cell function is impaired during pregnancy.
5
E
1
Platelet consumption during pregnancy is unchanged compared with that during prepregnancy.
null
null
null
null
5bb35384-1164-5b16-9064-d8903b2b2828
11. Which of the following drugs when administered to the mother is least likely to have clinical effects on the neonate?
Vecuronium
Propofol
Morphine
Diazepam
5
A
1
Ketamine
null
null
null
null
223e0e26-1ee2-5841-a3cd-7aee55f8ecc2
Which of the following drugs administered for postpartum hemorrhage (PPH) is incorrectly paired with a commonly associated side effect?
Carbetocin—hypotension
Oxytocin—hypernatremia
Misoprostol—fever
Methylprostaglandin—bronchoconstriction
5
B
1
Methylergonovine—arteriolar constriction
null
null
null
null
d720b6c5-5f5b-5b29-a753-9fd679f0476a
Which of the following drugs administered to reduce preterm labor is least likely to reduce preterm birth?
β-Adrenergic agonists
Magnesium sulfate
Progesterone
Calcium channel blockers
5
B
1
Indomethacin
null
null
null
null
fc646010-a555-5ad5-bb2e-72e8d0f624eb
A 22-year-old G2P1 is seen preoperatively for an anesthesia consultation at 32 weeks. She has a history of complex partial seizures since the age of 8 years and has been maintained on carbamazepine for the last several years with good control, and her last seizure was 19 months ago. Which of the following is NOT a common perinatal consequence of maternal antiepileptic drug use?
Small for gestational age
Decreased Apgar scores
Thromboembolic events
Admission to NICU
5
C
1
Preterm delivery
null
null
null
null
0a26c3e0-5d9e-5763-acf7-455d70fedd67
You are called to assist with an emergent general anesthesia for a 34-year-old G1P0 for nonreassuring fetal heart tones and persistent fetal bradycardia. During induction, you give propofol, succinylcholine, and fentanyl intravenously. Which of the following pharmacologic drug characteristics is most likely to be associated with an increased transfer of drugs across the placental membrane?
Lipophilic substances
Charged molecules
Molecular weight >1000 Da
Low free drug fraction
5
A
1
α-1-Acid glycoprotein binding
null
null
null
null
22a9228f-f15d-5ab1-8713-92c825edbbcb
Which of the following statements comparing chorionic villus sampling (CVS) with amniocentesis is most accurate?
Amniocentesis is associated with a risk of Rh isoimmunization; however, CVS is not.
CVS is safer than amniocentesis before 15 weeks of gestation.
Pregnancy loss following CVS and amniocentesis is directly related to provider experience.
Both techniques evaluate amniotic fluid and desquamated fetal cells (amniocytes) to perform genetic analysis.
5
B
1
Amniocentesis is contraindicated in patients with a history of pregnancy loss.
null
null
null
null
dfe78e90-01ec-5b32-9b52-33f8868582bd
17. Which of the following statements regarding oligohydramnios is most accurate?
The amniotic fluid volume can be influenced by acute fetal hypoxia or acute fetal CNS dysfunction.
Oligohydramnios secondary to amniocentesis carries a worse prognosis than other causes and rarely reverts to normal volumes of amniotic fluid.
The most common cause of oligohydramnios is fetal anomalies.
Uteroplacental insufficiency is not associated with oligohydramnios.
5
C
1
Hydrops fetalis is classically associated with oligohydramnios.
null
null
null
null
88647bbc-c04d-5a6a-8a16-a841cf4b5d2b
Which of the following statements regarding the etiology of hydrops fetalis is most correct?
Since the introduction of Rho(D) immune globulin, the most common causes of hydrops fetalis are nonimmune.
Maternal viral infections are not associated with hydrops fetalis.
Although the etiology of this condition must be addressed after delivery, the overall perinatal mortality associated with hydrops fetalis is <10%.
Non-ABO RBC antigens such as Kell, Rh(E), Rh(c), and Duffy are not associated with severe immune hydrops.
5
A
1
Isolated blunt abdominal trauma to a pregnant woman is not an indication for Rho(D) immune globulin.
null
null
null
null
5f357a70-2a73-531b-9de4-2938e2134f45
Which of the following variables is NOT included in a biophysical profile (BPP)?
Fetal limb movements
Fetal breathing movements
Fetal response to stimulation
Qualitative amniotic fluid volume
5
C
1
Fetal body movements
null
null
null
null
d3c8f1b5-316a-5e9e-8b87-f7740fa90aef
A 23-year-old G2P0 undergoes ultrasound at 38 weeks, which demonstrates an estimated fetal weight (EFW) of 4850 g. Which of the following statements is the correct statement regarding fetal macrosomia?
An EFW greater than 4500 g in a nondiabetic woman or greater than 5000 g in a diabetic woman may warrant an elective cesarean delivery.
Fetal macrosomia is associated with an increased risk of cesarean and instrumental vaginal delivery.
Fetal macrosomia is more accurately predicted by ultrasound than by Leopold maneuvers.
Induction of labor at 38 weeks for suspected fetal macrosomia is associated with improved maternal and fetal outcomes.
5
B
1
The risk of PPH is unchanged by the presence of fetal macrosomia.
null
null
null
null
96afea9c-4b55-5fa5-940f-c8d194dd3c9c
For which of the following urgent obstetric conditions would it be considered most appropriate to perform neuraxial anesthesia?
Placenta previa
Preterm footling breech
Uterine rupture with hemodynamic compromise
Severe obstetric hemorrhage
5
A
2
Profound fetal bradycardia
null
null
null
null
a88ab7c9-555c-51bd-b956-09c3c8a1c9ce
Which of the following symptoms is not consistent with a postdural puncture headache (PDPH)?
Improves with lying flat, worsened by sitting or standing
Neck stiffness
Tinnitus
Bifrontal distribution
5
E
1
Scalp tenderness
null
null
null
null
2b6d7784-f7c1-5970-a682-8b34e7aa1b2b
23. What is the anticipated change in oxygen consumption during a normal second stage of labor?
Unchanged
Increased by 20%
Increased by 50%
Increased by 70%
5
D
1
Increased by 100%
null
null
null
null
4b9ad33c-25a9-5273-99fb-9daf6a4d7c14
You are participating in the care of a complex obstetric patient who has a history of severe pulmonary arterial hypertension and is undergoing induction of labor. She is a G3P2 at 37 weeks with 2 prior vaginal deliveries and has had progressive dyspnea over the last month, and a multidisciplinary discussion with her cardiologist, maternal fetal medicine specialist, and anesthesia team took place before her admission. She has an epidural in place and is now fully dilated
At the beginning of the first stage of labor (onset of contractions, cervical dilation <5 cm)
At the end of the first stage of labor (full cervical dilation)
At the end of the second stage of labor (immediate postpartum period)
At the end of 24 hours after delivery
5
C
3
At the end of 72 hours after delivery
null
null
null
null
2a7e4f74-197c-5770-9d86-580772e8e565
A 23-year-old G1P0 woman with an uncomplicated pregnancy is now beginning the second stage of labor. Which of the following changes in respiratory physiology would be expected for this patient compared with prepregnancy?
Decreased tidal volume and increased respiratory rate
Increased tidal volume and increased minute ventilation
Decreased tidal volume and increased minute ventilation
Increased tidal volume and decreased respiratory rate
5
B
1
Increased tidal volume and decreased minute ventilation
null
null
null
null
c272098e-4ce3-541a-a36b-31b38270a19a
Which of the following statements regarding the effect of combined spinal epidural (CSE) anesthesia on progress of labor is most correct?
CSE anesthesia techniques accelerate the progress of the second stage of labor.
CSE anesthesia techniques increase the rate of instrumental vaginal delivery.
Early placement CSE anesthesia increases the risk of cesarean delivery when compared with later placement.
CSE anesthesia has no greater effect on the progress of labor than epidural anesthesia.
5
D
1
CSE has been shown to increase the risk of requiring a cesarean delivery compared with epidural anesthesia alone.
null
null
null
null
5ece50d2-33c4-5760-a459-bf67e0fe9637
A 31-year-old G2P0 woman with an epidural in place for labor analgesia has been actively pushing for the last 2 hours and 15 minutes. Her partner inquires whether this is a concerning duration of time. What would be considered a prolonged second stage of labor in this patient?
Second stage lasting more than 1 hour with neuraxial anesthesia
Second stage lasting more than 1 hour without neuraxial anesthesia
Second stage lasting more than 2 hours with neuraxial anesthesia
Second stage lasting more than 3 hours with neuraxial anesthesia
5
D
1
Second stage lasting more than 4 hours with neuraxial anesthesia
null
null
null
null
9249243e-eb12-5204-8432-eed4bad30447
Which of the following is not a strong indication for cesarean delivery?
Previous Pfannenstiel incision cesarean delivery
Placenta previa
Breech presentation
Prolapsed umbilical cord
5
A
1
Prior myomectomy
null
null
null
null
ef59cab2-de2b-53ec-aba3-85e63358029f
29. For which of the following conditions would general anesthesia be considered the preferred technique for a cesarean delivery?
High body mass index (BMI)/obesity
History of malignant hyperthermia
Severe psychiatric disorder
History of pulmonary disease
5
C
2
History of difficult intubation
null
null
null
null
2f2bf7db-fe39-5cda-a1eb-975e172b55d3
Which of the following pregnancy-related changes is least likely to contribute to airway complications during intubation?
Presence of a Mallampati class III or IV airway
Friable oral mucosa
Increased metabolic need and oxygen consumption
Decreased lower esophageal sphincter tone
5
E
2
Decreased duration of paralysis following succinylcholine administration
null
null
null
null
cf1b4f4e-dfa0-58f8-9ea8-2a3a4c024f91
You are asked to provide an anesthesia consultation for a 33-year-old G1P0 with a medical history significant for relapsing and remitting multiple sclerosis that was diagnosed 4 years before this pregnancy. She is currently not taking any medications, and her last relapse was 15 months ago. Her physical examination is significant only for right foot drop. Which of the following is the most appropriate management for her obstetric anesthesia?
Spinal and epidural analgesia are contraindicated for labor.
Spinal techniques are significantly safer than epidural techniques and are preferred for analgesia or anesthesia.
Epidural techniques are significantly safer than spinal techniques and are preferred for analgesia or anesthesia.
Spinal and epidural techniques are both considered to be safe and can be pursued for analgesia or anesthesia.
5
D
2
General anesthesia has been implicated in relapses of multiple sclerosis and should be avoided.
null
null
null
null
77119422-7141-5769-8cce-eca2c3026482
A 24-year-old G2P0 woman, 7 weeks pregnant based on the last menstrual period, presents to the ED with right lower quadrant pain, tachycardia, and
If on physical examination she has cervical dilation without fetal or placental expulsion, this would be considered a threatened abortion.
Spontaneous abortions are most commonly related to maternal immunologic phenomena.
Methotrexate may be used to treat this patient with suspected ectopic pregnancy.
The rate of serum β-hCG concentration rise is not reliable for the diagnosis of ectopic pregnancies.
5
E
1
Transvaginal ultrasound is the best modality to image if an ectopic pregnancy is suspected.
null
null
null
null
fae4f6a3-fc2b-53b1-96eb-25d45fd3e369
Which of the following statements is not true regarding systemic lupus erythematosus (SLE) in pregnancy?
Patients with SLE have an increased risk of preterm delivery.
The presence of atypical blood antibodies may make it challenging to obtain a blood type and crossmatch.
The presence of lupus anticoagulant increases the patient's risk of bleeding complications from neuraxial anesthesia.
Patients with SLE are at risk of pericarditis and cardiac tamponade.
5
C
1
Infants born to mothers with SLE may be born with congenital heart block.
null
null
null
null
93d0fc02-aef4-5cd7-af05-5f3cdeb70159
34. Which of the following hematologic disorders is not associated with an increased risk of thrombotic events in pregnancy?
Protein C deficiency
Antithrombin III deficiency
Disseminated intravascular coagulation
Von Willebrand disease
5
D
1
Antiphospholipid syndrome
null
null
null
null
dbc39872-e445-557b-b0a5-afaae47438f2
Which of the following statements regarding management of a parturient with mitral stenosis is most correct?
Percutaneous mitral balloon valvuloplasty may be considered during pregnancy in patients with severe disease who are refractory to medical management.
The physiologic changes of pregnancy are well tolerated with the peak period of symptoms in the first trimester that typically improves throughout gestation.
Peripartum β-blockers may be used but have been associated with worse maternal outcomes.
Percutaneous valvuloplasty should be performed postconception in patients withmoderate or severe mitral stenosis, as the clinical course during pregnancy is widely variable.
5
A
1
Epidural labor analgesia is not recommended given the risk of cardiovascular collapse.
null
null
null
null
ec1570ce-e82a-51a6-95af-951fda634026
Which of the following associations between findings from fetal heart rate (FHR) monitoring and their causes is most accurately paired?
Early decelerations—umbilical cord compression
Variable decelerations—fetal head compression
Late decelerations—umbilical cord compression
Sinusoidal pattern—fetal anemia
5
D
1
Accelerations—fetal distress
null
null
null
null
91ac74d5-ef6b-5a26-8ad7-332e9b192593
A 36-year-old G1P0 at 37 weeks' gestation presents to triage complaining of a severe headache and blurry vision. Her vital signs include T 37.8, HR 84, RR 28, and BP 190/114. Her laboratory evaluation is significant for proteinuria and shows a platelet count of 86 000/mm3 with normal coagulation studies. Which of the following steps of management is inappropriate?
Treatment of hypertension to a goal of 15%-25% reduction in mean arterial pressure with intravenous (IV) hydralazine
Initiating seizure prophylaxis with magnesium sulfate
Performing an epidural for labor analgesia
Placement of a radial arterial blood pressure catheter
5
E
3
Platelet transfusion to achieve a platelet count of >100 000 mm3 before performing neuraxial anesthesia
null
null
null
null
34a55d3e-6c05-58f9-955f-3df9ada40412
A 42-year-old G1P0 woman complains of shortness of breath 3 hours after undergoing cesarean delivery of a term infant. She was initially admitted for preeclampsia and had a prolonged induction during which time she received 5 L of crystalloid infusions. Which of the following is the most likely etiology of her hypoxemia?
Pulmonary embolism
Pulmonary edema
Spontaneous pneumothorax
Atelectasis
5
B
3
Pneumonia
null
null
null
null
23b633ac-c8ee-59ff-8a45-a9fa225d630a
39. Which of the following statements is most correct regarding umbilical cord prolapse during labor?
Vaginal delivery may be attempted if the diagnosis is made during the first stageof labor; however, if diagnosed in the second stage, then cesarean delivery should be performed.
Manual elevation of the presenting limb is contraindicated.
Neuraxial anesthesia should be attempted before the use of general anesthesia.
Macrosomia is associated with an increased risk of umbilical cord prolapse.
5
E
1
The risk of complications is decreased with a shorter interval from diagnosis to delivery.
null
null
null
null
364c3087-0fa0-506f-84ee-c4d8a292296d
Which of the following interventions is not recommended for aspiration prophylaxis in pregnant patients?
Ondansetron
Metoclopramide
H2 -receptor antagonists
Nonparticulate antacids
5
A
1
Avoidance of solid foods during labor
null
null
null
null
5c12121d-baba-57aa-8bf7-a35cb9ca3592
A 23-year-old G1P0 woman who just had a successful vaginal delivery with epidural analgesia now has persistent bleeding suspected to be related to retained placenta. Which of the following actions is the least appropriate to pursue for this patient's anesthetic management?
Use of oxytocin for increased uterine tone after manual removal of the placenta
Neuraxial anesthesia to achieve a block height of T6
Intermittent boluses of ketamine to facilitate extraction
Administering nitroglycerin spray to the mother
5
E
3
Transport to OR and induction of general anesthesia with 1.5-2 MAC (minimum alveolar concentration) of volatile anesthetic
null
null
null
null
3e0cbedb-de04-5605-91e5-f719ba0406f0
You are called to the bedside to evaluate a 31-year-old G2P1 at term who is attempting a trial of labor after cesarean (TOLAC) and is complaining of abrupt onset of abdominal pain despite previously adequate epidural analgesia. She has a history of a prior cesarean delivery for arrest of descent at 39 weeks. Which of the following statements regarding TOLAC and vaginal birth after cesarean (VBAC) is false?
Contraindications to VBAC include a previous classic incision uterine surgery.
Risk of uterine rupture is significantly increased in patients attempting a TOLAC.
The risk of maternal mortality is less in a TOLAC than that in an elective cesarean section.
Gestation beyond 40 weeks carries a higher risk of uterine rupture in an attempted TOLAC.
5
D
1
Increased BMI (>30) significantly decreases the likelihood of a successful VBAC.
null
null
null
null
45939f65-726a-5bda-98ae-e2b4aeb0cdcf
A 24-year-old G1P0 patient at 33 weeks' gestation with twins presents to triage with uterine contractions and a concern for preterm premature rupture of membranes. Which of the following complications of pregnancy is not consistently associated with multiple gestations?
Preterm labor
Acute fatty liver of pregnancy
Placental abruption
Postpartum hemorrhage
5
E
1
Gestational diabetes
null
null
null
null
2e447d47-78be-55ff-bc0e-abe3b752234a
Which of the statements below regarding preterm labor is most correct?
Preterm labor complicates roughly 5% of all pregnancies in the United States.
Birth weight of preterm neonates does not correlate with morbidity and mortality.
Urinary tract infections may predispose patients to preterm labor.
Neonatal benefits of maternal administration of corticosteroids in preterm labor are limited to pulmonary maturation.
5
C
1
Magnesium sulfate is preferred as a first-line agent for tocolysis in preterm labor.
null
null
null
null
1b8f385c-f168-54e0-b75f-fcec9cd9f56b
45. Which of the following statements is false regarding breech presentation and delivery?
External cephalic version is more likely to be successful if performed with general anesthesia.
Perinatal morbidity and mortality are greater in planned cesarean delivery than those in planned vaginal delivery.
Maternal morbidity is lower in planned cesarean delivery than that in planned vaginal delivery.
Institutional protocols for vaginal breech delivery to select appropriate candidates and labor management may be appropriate.
5
C
1
Fetal head entrapment during delivery may require administration of nitroglycerin to the mother.
null
null
null
null
50d82b12-6876-5bf9-a843-da17ea50bf24
A neonate, born with a heart rate of 109 beats per minute, is taking gasping irregular breaths, appears cyanotic, grimaces to stimulation, and flexes the extremities. Which of the following is the infant's Apgar score?
2
4
5
7
5
C
2
8
null
null
null
null
c84fa092-43e4-5a8f-be14-a8dea81a9773
A neonate is delivered at 38 weeks via cesarean section after a failed induction for intrauterine growth restriction. Which of the following is most likely to be associated with increased neonatal morbidity?
Two separate episodes of FHR late decelerations each lasting 90 seconds
An Apgar score of 6 at 1 minute after delivery
Umbilical artery pH of 7.18 and base deficit of 10 mmol/L
Umbilical artery pH less than 7.0 and base deficit of 14 mmol/L
5
D
1
Stage I hypoxic-ischemic encephalopathy
null
null
null
null
fa0c4a80-a347-5122-8330-97cb2cf5b6d0
A neonate is delivered at 35 weeks via an emergent cesarean section and is noted to have rapid shallow gasping, appears cyanotic, and has a heart rate of 110 beats per minute. Which of the following is the most appropriate next step in fetal resuscitation?
Continue to observe.
Provide positive pressure ventilation.
Provide blow-by supplementary oxygen.
Administer epinephrine.
5
B
2
Begin chest compressions.
null
null
null
null
59a0bda3-f4ef-5334-b9d1-d370ab2d9dff
You are caring for a 29-year-old G2P1 at 28 weeks' gestation with the pregnancy complicated by a fetal sacrococcygeal teratoma, who is presenting for an intrauterine surgical intervention. Which of the following statements is NOT true regarding intrauterine surgery?
Volatile anesthetic agents are used at 2-3 MAC for maintenance of anesthesia.
Magnesium and nitroglycerin may be used to provide tocolysis.
Maternal administration of paralytic agents is needed to ensure maternal and fetal immobility.
Vasopressor use to maintain placental perfusion is frequently required.
5
C
1
Subsequent pregnancies should be delivered via cesarean section rather than allowing labor.
null
null
null
null
ca75dbd4-a6be-586f-9bfc-0f921d5ee1a5
A healthy 24-year-old G2P1 at term with an epidural in place for analgesia who is currently at 7 cm cervical dilatation develops a late deceleration in the FHR tracing. Her current heart rate is 108 beats per minute, blood pressure is 80/47 mm Hg, and oxygen saturation is 97%on room air. Which of the following interventions is least likely to be beneficial for correction of fetal distress?
IV fluid bolus
IV bolus of phenylephrine
Terbutaline
Maternal repositioning
5
E
3
Maternal oxygen supplementation
null
null
null
null
d79cadc3-15b6-5f21-b399-e2e22114f5d9
A 64-year-old man with a medical history significant for Mobitz type II seconddegree heart block after permanent pacemaker (PPM) placement presents for video-assisted right upper lobe wedge resection for a pulmonary nodule. Which of the following intraoperative issues is unlikely to occur from electromagnetic interference (EMI)?
Increase in ventricular thresholds
Inhibition of pacemaker by EMI
Pacemaker battery failure
Transient or permanent loss of capture
4
C
1
null
null
null
null
null
78f47e09-9b94-5431-a66c-4bc8ad932266
Which of the following codes correctly describes a pacemaker that utilizes synchronous, dual-chamber pacing and is rate-responsive?
DOOR
DDDO
VVIR
DDIR
4
D
1
null
null
null
null
null
157201a3-b2cf-5534-b129-d25587b7e167
8. A 74-year-old man is 3 weeks after pulmonary vein isolation for atrial fibrillation and presents to the emergency department with fever, chills, and dysphagia. He is found to be hypotensive and anemic. Which of the following complications from pulmonary vein isolation commonly presents during this period?
Atrial-esophageal fistula (AEF)
Complete heart block
Cardiac tamponade
Phrenic nerve injury
4
A
1
null
null
null
null
null
5f162bdd-6680-5783-8131-138d0ca0373e
An otherwise healthy 26-year-old woman undergoing laparoscopic myomectomy develops intraoperative narrow-complex tachycardia at a rate of 170 beats per minute, with loss of P wave. Her blood pressure quickly drops to 55/30. Which of the following is the correct next step in treatment?
Diltiazem
Adenosine
Metoprolol
Synchronized cardioversion
4
D
2
null
null
null
null
null
78d1bb52-b5d9-5c3b-a160-00753dbf29a7
A 58-year-old woman one day after catheter ablation for atrial fibrillation complains of shortness of breath. Vital signs are as follows: 36.8°C | 74 | 134/68 | 26 | 98% on room air. ECG shows restoration of normal sinus rhythm. Chest Xray demonstrates an elevated right hemidiaphragm. Which of the following procedural complications is the most likely source of her dyspnea?
Volume overload
Phrenic nerve injury
Atrial-esophageal fistula
Cardiac tamponade
4
B
2
null
null
null
null
null
56ba7314-388f-5951-a4cd-08b39afb751d
Which of the following patients should undergo additional cardiac testing before proceeding for an intraoperative surgical procedure?
A 71-year-old man with known untreated 3-vessel coronary disease presenting for exploratory laparotomy for perforated bowel
An 81-year-old woman with chronic kidney disease (creatinine 2.3 mg/dL) and prior ischemic stroke presenting for lumpectomy for breast cancer
A 68-year-old man with type 2 diabetes mellitus and prior ischemic strokepresenting for revascularization procedure for peripheral arterial disease, which limits his exercise capacity
An otherwise healthy 48-year-old man presenting for median sternotomy for thymoma resection
4
C
3
null
null
null
null
null
3b80ebd2-bab9-5660-9031-9a78418f5cd6
A patient with type 1 diabetes mellitus and chronic kidney disease, stage III (Cr 2.5 mg/dL) presents for a video-assisted right upper lobe wedge resection for pulmonary nodule. Which of the following medications is appropriate to initiate preoperatively?
Metoprolol
Lisinopril
Amlodipine
Aspirin
4
A
2
null
null
null
null
null
1d97bff8-af4f-522e-b418-e0b7010df2f2
When used alone, which ECG lead will most likely detect intraoperative myocardial ischemia?
aVL
II
V4
V5
4
D
1
null
null
null
null
null
d316e6c7-fd64-5487-8d7f-f365e7b77a3d
14. A 59-year-old man with a suspected bowel perforation is scheduled to undergo exploratory laparotomy. His vitals are as follows: 38.2°C | 122 | 81/43 | 24 | 97% on 3 L nasal cannula. Laboratory analysis is notable for troponin of 0.12 ng/mL, and ECG shows ST depressions in leads V4 -V6 . Which of the following is the most appropriate diagnosis?
Unstable angina
Non-ST elevation myocardial infarction (MI), type I
Non-ST elevation MI, type II
ST elevation MI
4
C
3
null
null
null
null
null
5f8d574f-60cb-5e25-9171-1909181ce8cc
A 49-year-old man is undergoing retroperitoneal sarcoma resection, which has been complicated by an injury to the inferior vena cava (IVC) and substantial blood loss. You note ST depressions in lead II and send an arterial blood gas revealing the following information:
Increasing FiO2
Transfusion of 2 units of packed red blood cells
Administering rectal aspirin
Increasing phenylephrine infusion
4
B
2
null
null
null
null
null
b4e84e23-7570-5708-a6a7-6012fe9af85f
Which of the following statements is true concerning patients with ventricular assist devices (VADs) presenting for noncardiac surgery?
Noninvasive blood pressure cuffs will not function correctly in a patient with a VAD.
Anticoagulation should be held for at least 48 hours before proceeding to the operating room (OR).
Implantation of a VAD may delay gastric emptying and necessitate a rapid sequence induction.
Regional anesthesia should be utilized whenever possible for VAD patients.
4
C
2
null
null
null
null
null
f9f44cc8-2710-572b-b681-b5d11efc657c
Which of the following statements is true with respect to extracorporeal membrane oxygenation (ECMO) as compared with cardiopulmonary bypass (CPB)?
Arterial line tracing for both ECMO and CPB will lack pulsatility.
The membrane oxygenator in CPB is designed for longer-term use compared with ECMO.
The heart is stopped in both ECMO and CPB.
Lower flow rates are used in CPB, necessitating a greater degree of anticoagulation.
4
D
1
null
null
null
null
null
560d3ed0-d42e-590d-a328-5fd67db5edd0
Which of the following factors places a patient at increased risk of anaphylaxis to protamine during reversal of heparin following CPB?
Prior exposure to protamine
Diabetes treated with metformin
History of atopy (asthma, eczema)
Prolonged heparin time
4
A
1
null
null
null
null
null
1e5c7646-839c-54af-92c6-292536382b76
19. Which of the following is an advantage of traditional, on-pump coronary artery bypass grafting (CABG) as compared with off-pump coronary artery bypass grafting (OPCABG)?
Lower intraoperative blood loss
Reduced risk of postoperative cognitive dysfunction
Higher rates of graft patency
Reduced risk of thrombotic events
4
C
1
null
null
null
null
null
e6447c4b-c1c7-5a1d-82ca-97cd1282551f
Which of the following correctly describes the appropriate timing of inflation of an intra-aortic balloon pump?
Just after the dicrotic notch
At the onset of ventricular systole
When the P wave is seen on ECG
During isovolumetric contraction
4
A
1
null
null
null
null
null
e3934282-4f43-5a00-b816-4b2a8cdc6236
A patient with asymptomatic, moderate aortic stenosis (Vmax = 3.7 m/s) is presenting for elective laparoscopic colectomy for newly diagnosed colon cancer. Within what time frame should an echocardiogram have been performed before proceeding with elective surgery?
3 months
6-12 months
1-2 years
3-5 years
4
C
2
null
null
null
null
null
eeb42aa7-9f0a-58cc-9ef1-909c3124bec9
Which one of the following patients should receive infective endocarditis (IE) prophylaxis before undergoing his/her associated procedure?
A 61-year-old man with a mechanical mitral valve presenting for root canal
A 34-year-old woman with a history of repaired tetralogy of Fallot presenting for dental cleaning
A 54-year-old woman after aortic valve replacement for bicuspid aortic valvepresenting for elective cystoscopy
A 28-year-old man with history of IE because of IV drug use presenting for esophagogastroduodenoscopy
4
A
2
null
null
null
null
null
a1d33b4e-25ab-5166-91ab-d698077064c8
24. A 71-year-old man is presenting for elective aortic valve replacement. His transthoracic echocardiogram (TTE) shows a hypertrophic left ventricle (LV) with preserved function and an aortic valve area = 1.4 cm2 , Vmax = 3.4 m/s, and mean gradient = 37 mm Hg. He is currently asymptomatic and denies angina, syncope, and dyspnea. Which of the following statements is correct regarding his anesthetic management?
Phenylephrine infusion will decrease stroke volume because of increased afterload.
Atrial fibrillation will be poorly tolerated.
Heart rate between 80 and 100 beats per minute is ideal.
Dopamine is the inotrope of choice.
4
B
2
null
null
null
null
null
7ce216a5-450b-50fb-b1c2-4e6578445e60
A 61-year-old man with moderate mitral regurgitation (MR) is presenting for emergent exploratory laparotomy secondary to perforated bowel. Which of the following goals is most critical in the anesthetic management of MR?
Target heart rates at the upper limit of normal (80-100 bpm).
Increase preload slightly.
Maintain sinus rhythm.
Reduce SVR.
4
D
2
null
null
null
null
null
6b28279d-9d1d-5064-84ac-cebd41de5cd7
A otherwise healthy 24-year-old man with hypertrophic cardiomyopathy (HCM) is undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis. He becomes acutely hypotensive following insufflation of the abdomen and positioning in the reverse Trendelenburg position. His blood pressure is unchanged at 68/43 following a rapid bolus of IV fluids, lightening the anesthetic and leveling the bed. Administration of which of the following drugs is the most appropriate next step in management?
Epinephrine 10 µg IV
Ephedrine 5 mg IV
Norepinephrine 4 µg IV
Phenylephrine 100 µg IV
4
D
3
null
null
null
null
null
491ee193-a732-5189-a24f-de27591ee8c4
Which of the following statements is true with regard to anesthetic management of patients with HCM?
Patients without outflow obstruction at rest are at low risk for dynamic obstruction with administration of anesthetic agents.
Negative inotropic agents may be useful to attenuate sympathetic stimulation perioperatively.
Hypovolemia is better tolerated than hypervolemia.
Lethal arrhythmias do not occur in hypertrophic obstructive cardiomyopathy patients without signs of inducible obstruction on echocardiography.
4
B
2
null
null
null
null
null
ffa98143-17c7-51fa-9ad9-70fd65848de0
A 69-year-old woman becomes hypertensive to 207/109 upon emerging from a general anesthetic for laparoscopic hysterectomy. She is subsequently hypoxic and her endotracheal tube has frothy clear secretions. Which of the following is the most likely diagnosis?
Volume overload
Negative pressure pulmonary edema
Flash pulmonary edema
Transfusion-associated circulatory overload
4
C
3
null
null
null
null
null
18d7b990-5550-5a2a-8d4a-4aa877b6f069
A 54-year-old woman who was previously healthy presents with severe malaise and light-headedness 2 weeks after her husband died unexpectedly. Her extremities are cool and clammy, she is found to be profoundly hypotensive, and transthoracic echocardiogram shows global LV hypokinesis with apical ballooning. Which of the following statements is correct about her condition?
Postmenopausal women are at highest risk for this condition.
ECG changes are uncommon at presentation.
This condition is unlikely to resolve over time.
Most patients affected by this condition have underlying coronary artery disease.
4
A
1
null
null
null
null
null
fde7962a-930b-57ac-96b1-764338e6e667
30. A 74-year-old man with diabetes mellitus and poorly controlled hypertension has undergone robotic prostatectomy over a course of 8 hours, during which he received 4 L of Lactated Ringer and 500 cc of 5% albumin. Blood loss was approximately 200 cc, and urine output was 320 cc. His oxygen saturation is 93%-95% despite FiO2 of 100% and positive end-expiratory pressure of 8 cm H2O. On auscultation, bibasilar crackles are present. Which of the following is the best next step in management?
Emerge the patient and extubate to noninvasive positive pressure ventilation (PPV) in the OR.
Keep the patient intubated and admit to the surgical intensive care unit.
Administer a loop diuretic.
Initiate therapy with inhaled nitric oxide.
4
C
3
null
null
null
null
null
d2e1d308-7d3d-5e4d-8799-021db5c4636a
Which of the following signs or symptoms is more likely to be a presenting feature when cardiac tamponade develops chronically, rather than acutely?
Hypotension
Edema
Light-headedness
Cough
4
B
1
null
null
null
null
null
2b582a3d-ff9e-500a-8eb5-b28ca84c8cd4
Which of the following causes of cardiac tamponade is an indication for immediate surgical intervention?
Viral pericarditis
Metastatic lung cancer
Free wall rupture following MI
Systemic lupus erythematosus
4
C
1
null
null
null
null
null
9edb7abf-89c3-5ae0-b8d5-f6c86d2012e9
Which of the following conditions will mask the pulsus paradoxus commonly seen in cardiac tamponade?
Positive pressure ventilation
Mucous plug
Stridor
Chronic obstructive pulmonary disease (COPD)
4
A
1
null
null
null
null
null
d361dfe0-2565-56f7-a3c6-9db07e4beca4
A 67-year-old man presents with progressive dyspnea on exertion and intermittent positional chest discomfort. His past medical history is significant for coronary artery disease for which he underwent a 3-vessel CABG 2 years ago. Coronary catheterization shows patent grafts. Transthoracic echocardiography demonstrates evidence of increased ventricular interdependence and dissociation of intrathoracic-intracardiac pressures. Which of the following is the most likely cause of this patient's constrictive pericarditis (CP)?
Tuberculosis
Rheumatologic
Postradiation
Postcardiac surgical
4
D
2
null
null
null
null
null
cba61d18-0a02-583f-8ffc-1fb090d9280e
The presence of which of the following findings is more consistent with a diagnosis of restrictive cardiomyopathy (RCM) as compared with CP?
Expiratory flow reversal in the hepatic vein
Respirophasic septal shift
Moderate pulmonary hypertension
Elevated medial mitral annulus velocity (e,) ≥ 8 cm/s
4
C
2
null
null
null
null
null
f575a4f4-9039-5720-b3fb-b413557cd49e
36. Which of the following statements is true of perioperative venous
Novel oral anticoagulants are more effective than once-daily enoxaparin in VTE prophylaxis without increased rates of postoperative bleeding.
Major trauma increases VTE risk to a greater degree than postpartum status.
The VTE prophylactic effects of aspirin and warfarin are synergistic.
Neuraxial anesthesia initiated before surgical incision reduces rates of perioperative VTE.
4
D
1
null
null
null
null
null
97054359-6ab8-526b-bc0c-65839ca1417b
A 48-year-old man presents for retroperitoneal sarcoma resection. Pharmacologic VTE prophylaxis should be continued postoperatively for what length of time?
3 days
14 days
28 days
60 days
4
C
1
null
null
null
null
null
ea276da0-28b5-50f3-b24f-c92c55858e8d
Which of the following pathophysiologic changes occurs with a pulmonary embolism?
Increased dead space
Increased shunt
Reduced pulmonary vascular resistance
Reflex bronchodilation
4
A
1
null
null
null
null
null
7b0e1ea1-18d4-581b-995e-3ea08520c51a
Which of the following arterial blood gas results, on an FiO2 of 0.4, is most consistent with a diagnosis of acute, submassive pulmonary embolism?
| pH 7.39 | PaCO2 44 | PaO2 90 | HCO3 26 |
| pH 7.47 | PaCO2 40 | PaO2 74 | HCO3 28 |
| pH 7.59 | PaCO2 28 | PaO2 90 | HCO3 26 |
| pH 7.50 | PaCO2 32 | PaO2 74 | HCO3 24 |
4
D
2
null
null
null
null
null
8d05f78c-6eba-5231-b10c-821f718861ce
Which of the following ECG findings is most sensitive for acute pulmonary embolus?
Incomplete right bundle branch block
Rightward axis
Sinus tachycardia
Large S wave in lead I, combined with Q wave and inverted T wave in lead III
4
C
1
null
null
null
null
null
236acb71-5de5-5419-8b82-68c16984c8de
A 59-year-old woman with a history of hypertension presents for total abdominal hysterectomy for endometrial cancer. She has continued her home amlodipine and metoprolol up until the day of surgery but has held her lisinopril for 2 days. In the preoperative day, she is very anxious and her blood pressure is 179/88. Which of the following is the most appropriate next step?
Cancel the case.
Administer home lisinopril dose.
Proceed with the case and maintain blood pressure within high-normal range.
Administer appropriate anxiolysis and reassess.
4
D
3
null
null
null
null
null
267ee312-185e-599d-87b0-3870db66530b
42. Which of the following statements is true with respect to essential hypertension?
Systolic dysfunction will precede diastolic dysfunction in the progression.
LV eccentric hypertrophy is likely to occur.
Essential hypertension accounts for >80% of all hypertension diagnoses.
Cerebral autoregulation is unchanged with long-standing essential hypertension.
4
C
1
null
null
null
null
null
7f9598b0-ffb9-5a36-916c-025aca7ead3f
Which of the following antihypertensives should be held for 12-24 hours preoperatively?
Captopril
Labetalol
Amlodipine
Clonidine
4
A
1
null
null
null
null
null
c7516c0a-2568-54ec-a17c-944974bedb1a
In which of the following scenarios should a β-blocker be initiated preoperatively?
A 60-year-old woman presenting for bilateral mastectomy with poorly controlled hypertension on lisinopril, amlodipine, and hydrochlorothiazide
A 48-year-old man with 100-pack-year smoking history presenting for thoracoscopic lobectomy
A 74-year-old man with coronary artery disease presenting for endovascular aortic aneurysm repair (EVAR)
A 65-year-old woman with hypertension and hyperlipidemia presenting for laparoscopic cholecystectomy for acute cholecystitis
4
C
2
null
null
null
null
null