Chapter 42: Pediatric and Adolescent Gynecology

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. The primary care pediatric nurse practitioner is prescribing contraception for an adolescent
who has not used birth control previously. The adolescent has a normal exam and has no
family history of cardiovascular and peripheral vascular disease or diabetes. Which
preparation is used initially?
a. A combination oral contraceptive pills (OCP) with 30 to 35 mcg of estrogen and
low progestin
b. A combination OCP with low androgenic potency, such as Ortho-Cyclen
c. A progestin-only mini-pill oral contraceptive
d. A subdermal implant contraception, such as Implanon or Nexplanon
ANS: A
The usual initial OCP is a combination with 30 to 35 mcg of estrogen and low progestin
potency. The combination OCP with low androgenic potency is used for adolescents with
hirsutism or PCOS. The progestin-only mini-pill is used in patients for whom progestin is
contraindicated, such as for lactating women, and is not generally used in adolescents because
of irregular bleeding and higher failure rates. The subdermal implants are used in older
adolescents who are committed to long-term contraception.

2. An adolescent female tells the primary care pediatric nurse practitioner that she had
unprotected sexual intercourse 4 days prior and is worried she might become pregnant. What
will the nurse practitioner do?
a. Prescribe ulipristal acetate
b. Recommend levonorgestrel
c. Start a combination OCP at regular doses.
d. Suggest using the less expensive After Pill preparation.
ANS: A
The prescription medication ulipristal can be used up to 5 days after unprotected intercourse.
Levonorgestrel, which is the active ingredient in Plan B and the After Pill, should be taken
within 72 hours of unprotected intercourse. The After Pill must be purchased online. A
combination OCP may be used, but it is an alternative approach.

3. A 16-year-old female reports dull, achy cramping pain in her lower abdomen lasting 2 or 3
hours that occurs between her menstrual periods each month. The adolescent is not sexually
active. What is the treatment for this condition?
a. Abdominal ultrasound to rule out ovarian cyst
b. Oral contraceptives to suppress ovulation
c. Prostaglandin inhibitor analgesics and a heating pad
d. Referral to a pediatric gynecologist
ANS: C
 The adolescent is experiencing mittelschmerz pain, which is thought to occur when the follicle
ruptures at the time of ovulation. Unless the pain is severe, the adolescent should be reassured
and offered strategies to relieve discomfort, such as a heating pad and NSAIDs. The pain is
intermittent and occurs between periods; if it were persistent and severe, abdominal US would
be indicated. Oral contraceptives are rarely used to suppress ovulation when symptoms are
severe. Referral to a pediatric gynecologist is not indicated.

4. A 17-year-old sexually active female who began having periods at age 14 reports having
moderate to severe dull lower abdominal pain associated predominantly with periods but that
occurs at other times as well. The history reveals a recent onset of these symptoms. A
pregnancy test is negative. Which course of action is most important?
a. Perform a full diagnostic workup to evaluate potential causes.
b. Prescribe a prostaglandin synthetase inhibitor.
c. Start a 3- to 6-month trial of oral contraceptive pills.
d. Suggest using transcutaneous electrical nerve stimulation.
ANS: A
This adolescent has symptoms consistent with secondary dysmenorrhea and should have a full
diagnostic workup to evaluate potential causes. Prostaglandin synthetase inhibitors, OCPs,
and TENS are useful to treat discomfort, but determining the cause is more important.

5. A 15-year-old female has a positive pregnancy test and asks the primary care pediatric nurse
practitioner not to tell her parents. She is tearful and says she isn’t sure she wants to keep the
baby. What will the nurse practitioner do first?
a. Determine the state-mandated reporting laws.
b. Encourage the adolescent to talk to her parents.
c. Obtain a social work consult to discuss adoption options.
d. Refer her to a prenatal care specialist for follow-up.
ANS: A
The PNP should first determine what the state’s reporting laws are in case there are mandatory
provisions for reporting statutory rape. The other options may be correct, depending on the
laws and on the decisions of the adolescent.

6. A 16-year-old female reports breast tenderness and a “lump.” The primary care pediatric nurse
practitioner palpates a small fluid-filled mass in her right breast. A pregnancy test is negative.
Which action is correct?
a. Obtain a CBC to rule out infection.
b. Order an ultrasound of the mass.
c. Prescribe NSAIDs to treat her discomfort.
d. Reassure her that the findings are normal.
ANS: B
A cyst is usually a fluid-filled mass and should be evaluated by ultrasound to confirm this.
The mass is not warm or consistent with mastitis, so a CBC is not indicated. NSAIDs may be
offered once the diagnosis is confirmed. If the US reveals a cyst, reassurance can be given.

7. A 16-year-old female has not had a menstrual period yet and is concerned. She denies sexual
activity. An exam reveals an adult sexual maturity rating. Which laboratory test will the
primary care pediatric nurse practitioner order initially?
a. Genetic test for Turner syndrome
 b. Pituitary hormone tests
c. Pregnancy test
d. Thyroid function tests
ANS: C
When amenorrhea occurs, initial laboratory studies should include a pregnancy test regardless
of sexual history. Other tests are ordered after pregnancy is ruled out.

8. An adolescent female has heavy periods that are also irregular. The physical exam is normal.
A complete blood count reveals a hemoglobin of 8.9 g/dL. What test will the primary care
pediatric nurse practitioner order next?
a. Coagulation studies
b. C-reactive protein
c. Thyroid function
d. Ultrasound of pelvis
ANS: A
If the patient’s hemoglobin is low, coagulation studies should be ordered. CRP is ordered if
infection is suspected. Thyroid function is indicated if systemic disease is suspected. A pelvic
ultrasound is ordered if a mass is palpated, anomaly is suspected, bimanual exam cannot be
completed, or if the condition is unresponsive to treatment.

9. A sexually active adolescent female tests positive for N. gonorrhoeae and C. trachomatis. She
tells the primary care pediatric nurse practitioner that she wants to be treated today since she is
moving out of town the next day. What will the nurse practitioner order?
a. Azithromycin 1 g PO in a single dose
b. Ceftriaxone 250 mg IM and azithromycin 1 g PO one time each
c. Doxycycline 100 mg PO bid for 7 days
d. Erythromycin base 500 mg PO qid for 7 days
ANS: B
Follow-up cultures for gonorrhea are required unless ceftriaxone is used. Azithromycin is used
to treat both gonorrhea and chlamydia. The other options involve twice daily and four times
daily dosing, which present difficulties with compliance.

10. A 16-year-old sexually active female has a fever, bilateral lower abdominal pain, and malaise.
A speculum and bimanual exam reveals adnexal tenderness. The urinalysis is normal and
cervical cultures are pending. What medications will the primary care pediatric nurse
practitioner prescribe for this patient?
a. Azithromycin, doxycycline, and penicillin
b. Cefotaxime, azithromycin, and penicillin
c. Ceftriaxone, doxycycline, and metronidazole
d. Doxycycline, penicillin, and metronidazole
ANS: C
Patients with suspected pelvic inflammatory disease (PID) may be given ceftriaxone 250 mg
IM once, doxycycline 100 mg PO bid for 14 days, and metronidazole 500 mg PO bid for 14
days. The other options are not recommended by the CDC.