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nr509 chapter 21 27 interactive questions.
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Chapter 21 Female Genitalia1) A 45-year-old driver’s education instructor presents to the clinic for heavy periods and
pelvic pain during her menses. She reached menarche at age 13 years and has had regular
periods except during her pregnancies. She is a G4P3013 and does not use birth control as her
husband has had a vasectomy. She states this has been going on for about a year but seems to
be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass
halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is
normal. Her body mass index (BMI) is 27. What is the best explanation for her physical
finding?
a. Large colonic stool
b. Ovarian mass
c. Fibroids
d. 4-Month pregnancy
e. Bartholin gland
enlargement Correct Answer:
(c) Fibroids
Rationale: Fibroids, also known as myomas, are very common benign uterine tumors that can
become quite enlarged. Large colonic stool is incorrect. Stool cannot be easily palpated in the
abdomen except in a very thin person. Ovarian mass is incorrect. The mass palpated is in the
midline and ovarian masses will generally be in the adnexal area. In this case, the adnexal area
had no palpable mass. Four-month pregnancy is incorrect. This patient’s husband has had a
vasectomy, and this patient had menses last week. Bartholin gland enlargement is incorrect. An
enlarged Bartholin gland is noted in the labial area and not in the abdomen.
2) 2. A 32-year-old G0 woman comes for evaluation on why she and her husband have been
unable to get pregnant. Her husband has been married before and has two other children, ages 7
and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever
since. She began oral contraceptive pills from when she got married until last year, when she
began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a
history of five prior partners. She relates she was once treated for a severe genital infection when
she was in college. Based on this patient’s history, what is the best explanation for her
infertility?
a. Prior pelvic inflammatory disease (PID)
b. Prior Bartholin gland infection
c. Prior herpes infection
d. Metabolic disorder with subsequent hormonal irregularities leading to anovulation
e. Secondary amenorrhea
,Correct answer: (a) Prior pelvic inflammatory disease (PID)
Rationale: PID is a genital infection caused by gonorrhea, chlamydia, and other organisms. If
not treated early enough it can lead to tubal pregnancies or infertility. Prior Bartholin gland
infection is incorrect. Although Bartholin cyst infections can be from sexually transmitted
infections, they are only located on the labia and do not lead to fertility issues. Prior herpes
infection is incorrect. Herpes generally only affects the labial tissues, vagina, and cervix.
Although a baby delivered through an outbreak can suffer complications from maternal herpes,
it does not affect fertility.
Metabolic disorder with subsequent hormonal irregularities leading to anovulation is incorrect.
Although metabolic disorder does lead to anovulation and infertility problems, this patient
relates being regular all of her life so most likely has no hormonal abnormalities. Secondary
amenorrhea is incorrect. Secondary amenorrhea occurs when a woman having periods stops
having them for some reason. This woman has not had an absence of her menses.
3. A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3
years ago and was normal. She is a G0 and is currently not sexually active although she has
had two lifetime partners. She is on oral contraceptive pills for cycle control and has no
medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and
places the speculum. There are two layers of cells, squamous and columnar. Where is the
most important area to obtain cells for a Pap smear?
a. Zona reticularis
b. Transformation zone
c. Squamous zone
d. Columnar zone
e. Linea nigra
Correct answer: (b) transformation zone
Rationale: The transformation zone is where cancerous cells are most likely to develop and is
thus the most important area to sample in a Pap test. Zona reticularis is incorrect. This is actually
a part of the adrenal glands that produces hormones. Squamous zone and columnar zone are
incorrect. Although each of these can be affected by the human papillomavirus, the
transformation zone where these two meet (and columnar cells become squamous cells) is the
area of most pathological activity and thus the area that is most important to sample during a Pap
smear. Linea nigra is incorrect. The linea nigra is actually the pigmented line often seen in the
midline with pregnant women.
4. A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 4
years ago and normal. She is a G1P1 with a 6-year-old child. She has had four lifetime
partners
,but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is
done followed by a bimanual examination during which a rectovaginal mass is palpated.
Which of the following exam findings would be most reassuring that this is not a colonic
mass?
a. No cervical motion tenderness
b. No pus from the os
c. The mass dents with digital pressure
d. Both adnexa are nontender
e. The perineum has no lesions
Correct answer: (c) The mass dents with digital pressure
Rationale: Stool in the rectum simulates a rectovaginal mass. Unlike a malignant mass it is
dented by digital pressure reassuring the examiner. A rectovaginal exam will confirm the
distinction. No cervical motion tenderness is incorrect. This reassures the examiner that there is
no pelvic inflammatory disease (PID), ectopic pregnancy, or appendicitis. No pus from the os
is incorrect. No pus reassures the examiner that there is no PID or cervicitis. Both adnexa are
nontender is incorrect. The adnexa being nontender is reassuring that there is no tubo-ovarian
infection or ovarian artery torsion. The perineum has no lesions is incorrect. No lesions would
indicate there is no active human papillomavirus warts or herpes infection.
5. A 21-year-old college student presents for her first annual exam. She has been sexually
active for 1 year and has had two partners. She is not aware of having had any sexually
transmitted diseases (STIs). She is using condoms for birth control and STI prevention but
admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum
exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description
for these lesions?
a. Several shallow ulcers with a red base
b. Translucent nodules
c. Raised friable or lobed lesions
d. Bright red, soft lesion arising from the cervical canal
e. Strawberry cervix (small red granular spots or
petechiae) Correct answer: (c ) Raised friable or lobed
lesions
Rationale: Warts or condylomata are raised lesions that are often lobed in appearance. With
addition of acetic acid, they will often turn white. Several shallow ulcers with a red base is
incorrect. These are associated with herpetic infections. Translucent nodules is incorrect. This is
a description of retention cysts or nabothian cysts. Bright red, soft lesion arising from the
cervical canal is incorrect. This is a description of a cervical polyp. Strawberry cervix (small red
, granular spots or petechiae) is incorrect. This is a common description of the cervix with
a Trichomonas infection.
6. A 23-year-old female comes to the clinic to discuss her birth control options. Although she
has been sexually active since age 16 years, she has been with one partner for the last year. She
has decided to discontinue condoms and would like a different birth control option. She has not
had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually
transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she
is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the
clinician elects to postpone her speculum exam. What is the best explanation for the decision to
postpone her exam?
a. She is on her menses.
b. She has only one current partner and does not need STI testing.
c. She had a normal Pap smear within the last 3 years.
d. She should not be sexually active.
e. She has been using condoms.
Correct answer: (a) She is on her menses.
Rationale: For best results with either a Pap smear or STI testing it is best to not have the
patient menstruating. On conventional Pap smears, blood masks the cytology. For STI testing,
the vaginal sample results are not always valid. Some practices do use urine STI testing but this
is not yet universally available. She has only one current partner and does not need STI testing
is incorrect. Until the age of 25 years, high-risk individuals with a history of several partners are
still tested yearly. She had a normal Pap smear within the last 3 years is incorrect. Although she
does not need a Pap smear at this time, she still needs STI testing. She should not be sexually
active is incorrect. This is a personal judgment of the provider and should not be involved in
decision making for the patient’s care. She has been using condoms is incorrect. As long as a
patient has not used a condom for the last 48 hours, there is no need to postpone a speculum
exam due to general condom usage.
7. An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge.
She states that it is thick and yellow and that she has had some recent pelvic pain. She is
sexually active and is not using any type of birth control or sexually transmitted infection (STI)
prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had
some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week.
After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization
of purulent discharge in which of the following areas would best support a diagnosis of PID?
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