PANCE (Physician Assistant National Certifying Exam) — All Questions
8 questions
A 28-year-old woman is 7 weeks past her last menstrual period with lower abdominal pain and spotting. Serum hCG is 4,800 mIU/mL, transvaginal ultrasound shows no intrauterine pregnancy and a complex adnexal mass with free fluid. She becomes hypotensive and tachycardic. What is the most appropriate management?
- a.Intramuscular methotrexate
- b.Expectant management at home
- c.Repeat hCG in 48 hours
- d.Emergency surgery✓
A positive hCG with no intrauterine pregnancy and an adnexal mass with free fluid indicates ectopic pregnancy, and hemodynamic instability suggests rupture, which requires emergency surgery (laparoscopy or laparotomy if unstable). Methotrexate is for stable, unruptured ectopic pregnancies meeting criteria. Repeat hCG or expectant care is inappropriate in a hemodynamically unstable patient.
A 26-year-old at 34 weeks' gestation has a blood pressure of 168/112 mm Hg, severe headache, 3+ proteinuria and right upper quadrant pain. She had normal blood pressure before 20 weeks. Which medication is given to prevent eclamptic seizures?
- a.IV phenytoin
- b.IV levetiracetam
- c.IV magnesium sulfate✓
- d.Oral lorazepam
New hypertension with proteinuria after 20 weeks with severe features is preeclampsia, and IV magnesium sulfate is the agent used to prevent (and treat) eclamptic seizures, alongside antihypertensive therapy and planning delivery. Phenytoin, benzodiazepines and levetiracetam are less effective than magnesium for eclampsia prophylaxis.
A 31-year-old at 32 weeks' gestation has sudden painless bright red vaginal bleeding. The uterus is soft and nontender, and fetal heart tracing is reassuring. Until placental location is known, which action should be avoided?
- a.Continuous fetal heart monitoring
- b.Transabdominal ultrasound
- c.Establishing IV access
- d.Digital cervical examination✓
Painless bright red bleeding in the third trimester with a soft uterus suggests placenta previa, and digital cervical examination is avoided until ultrasound excludes previa because it can provoke heavy hemorrhage. Ultrasound localizes the placenta, and fetal monitoring and IV access are appropriate. Painful bleeding with a tender, firm uterus would instead suggest placental abruption.
A 29-year-old woman has a thin gray-white vaginal discharge with a fishy odor that worsens after intercourse. Vaginal pH is 5.0, a whiff test with KOH is positive, and many epithelial cells are coated with bacteria. Which is the recommended treatment?
- a.Topical clotrimazole
- b.Intramuscular ceftriaxone
- c.Oral fluconazole
- d.Oral metronidazole✓
Thin gray discharge, pH above 4.5, a positive whiff test and clue cells meet Amsel criteria for bacterial vaginosis, treated with metronidazole (oral or vaginal) or vaginal clindamycin (CDC STI Treatment Guidelines 2021). Fluconazole and clotrimazole treat candidiasis, which has a normal pH and thick white discharge. Ceftriaxone treats gonorrhea.
Fifteen minutes after a vaginal delivery of a 4.3-kg infant, a woman has heavy bleeding. The placenta was delivered intact and no lacerations are seen. The uterus feels soft and boggy above the umbilicus. What are the most appropriate first measures?
- a.Packing the vagina and observing
- b.Uterine massage and IV oxytocin✓
- c.IV tranexamic acid as the only treatment
- d.Immediate hysterectomy
A soft, boggy uterus after delivery of a large infant points to uterine atony, the most common cause of postpartum hemorrhage, treated first with uterine massage, uterotonics such as oxytocin, and fluid resuscitation. Hysterectomy is a last resort. Vaginal packing does not contract the uterus, and tranexamic acid is an adjunct rather than a substitute for treating atony.
A 37-year-old woman who smokes a pack of cigarettes daily asks to start a combined estrogen-progestin oral contraceptive. Which feature of her history is a contraindication to this method?
- a.Her smoking at age 35 or older✓
- b.A prior uncomplicated cesarean
- c.Her history of irregular menses
- d.A family history of ovarian cancer
Smoking in a woman 35 years or older is a contraindication to combined estrogen-progestin contraceptives because of increased thromboembolic and cardiovascular risk; migraine with aura and severe hypertension are other examples. Irregular menses, a family history of ovarian cancer (combined pills lower ovarian cancer risk), and a remote uncomplicated cesarean are not contraindications.
A 44-year-old woman at average risk for breast cancer asks about mammography. Under the 2024 USPSTF recommendation, what is advised?
- a.Mammography every 2 years starting now✓
- b.Annual breast MRI instead of mammography
- c.No mammography until age 50
- d.Mammography every 5 years from age 40
The 2024 USPSTF final recommendation advises biennial screening mammography for women aged 40 to 74 years (grade B), so a 44-year-old at average risk should be screened every 2 years. Breast MRI is reserved for high-risk women. Starting at 50 reflects the older 2016 recommendation, and a 5-year interval is not recommended.
A 26-year-old Rh(D)-negative woman at 28 weeks' gestation has a negative antibody screen, and the father's Rh status is unknown. What is recommended at this visit?
- a.Start weekly middle cerebral artery Dopplers
- b.Give Rho(D) immune globulin only after delivery
- c.Repeat the antibody screen at delivery only
- d.Give Rho(D) immune globulin✓
An unsensitized Rh(D)-negative pregnant patient should receive Rho(D) immune globulin at about 28 weeks, again within 72 hours of delivering an Rh-positive infant, and after events such as bleeding or amniocentesis. Waiting until delivery misses antenatal sensitization. Middle cerebral artery Doppler surveillance is for patients already alloimmunized.