1
Barkley WHNP Comprehensive Board Review Exam
| 100 Questions and Verified Answers
Section 1: Obstetrics & Antepartum Care (Questions 1-25)
1. A 28-year-old G2P1 at 32 weeks gestation presents with a blood pressure of
150/95 mmHg and 2+ proteinuria on urine dipstick. She denies headache, visual
changes, or epigastric pain. Deep tendon reflexes are 3+ with mild clonus.
Which of the following is the most accurate classification of her condition?
A. Gestational hypertension
B. Chronic hypertension
C. Preeclampsia without severe features
D. Preeclampsia with severe features
RATIONALE: Preeclampsia is defined by new-onset hypertension (systolic ≥ 140
mmHg or diastolic ≥ 90 mmHg) after 20 weeks gestation with proteinuria or
evidence of end-organ dysfunction. Severe features include systolic BP ≥ 160
mmHg or diastolic BP ≥ 110 mmHg, thrombocytopenia (< 100,000/µL), impaired
liver function (transaminases > twice normal, severe RUQ/epigastric pain), renal
insufficiency (serum creatinine > 1.1 mg/dL or doubling of baseline), pulmonary
edema, or new-onset cerebral/visual disturbances. This patient's BP of 150/95
does not reach the severe threshold. While hyperreflexia and clonus are
concerning, they do not independently constitute severe features without the
above criteria.
• A: Gestational hypertension – Incorrect. This requires new-onset
hypertension after 20 weeks WITHOUT proteinuria. The presence of 2+
proteinuria moves the diagnosis to preeclampsia.
• B: Chronic hypertension – Incorrect. This is hypertension diagnosed before
pregnancy or before 20 weeks gestation. This patient's hypertension is new
after 20 weeks.
• D: Preeclampsia with severe features – Incorrect. Her blood pressure is
150/95, which does not meet the severe threshold of 160/110. She lacks
other severe features such as thrombocytopenia, elevated liver enzymes, or
pg. 1
,2
cerebral/visual symptoms. Clonus and hyperreflexia alone do not define
severe features.
2. A 32-year-old G1P0 at 28 weeks gestation presents with a 1-hour glucose
challenge test (GCT) result of 155 mg/dL. Which of the following is the most
appropriate next step?
A. Diagnose gestational diabetes mellitus and begin dietary counseling
B. Order a 3-hour 100-gram oral glucose tolerance test (OGTT)
C. Order a fasting blood glucose and hemoglobin A1c
D. Reassure the patient that the result is normal
RATIONALE: The 1-hour 50-gram glucose challenge test (GCT) is a screening test
for gestational diabetes mellitus (GDM). A value ≥ 130-140 mg/dL (depending on
institutional cutoffs) is considered a positive screen. This 155 mg/dL result
exceeds the common threshold of 130-135 mg/dL, indicating the need for
diagnostic testing. The definitive diagnostic test is the 3-hour 100-gram oral
glucose tolerance test (OGTT). GDM is diagnosed if two or more values on the
OGTT meet or exceed the Carpenter-Coustan criteria.
• A: Diagnose GDM and begin dietary counseling – Incorrect. The GCT is a
screening test, not diagnostic. A single elevated GCT alone is insufficient to
diagnose GDM; confirmatory testing is required.
• C: Order fasting glucose and A1c – Incorrect. While fasting glucose is
sometimes used in non-pregnant populations, the standard of care for
diagnosing GDM in pregnancy is the 3-hour OGTT. A1c is not validated for
diagnosing GDM.
• D: Reassure the patient the result is normal – Incorrect. A result of 155
mg/dL on the 1-hour GCT exceeds standard screening thresholds and
requires further evaluation.
3. A 26-year-old G1P0 at 10 weeks gestation presents with severe nausea and
vomiting, weight loss of 8 pounds, and ketonuria. She is unable to tolerate oral
intake. Which of the following is the most appropriate initial management?
A. Prescribe oral ondansetron and schedule a follow-up in 1 week
B. Recommend small, frequent meals and ginger supplementation
pg. 2
,3
C. Admit for intravenous fluids, antiemetics, and electrolyte monitoring
D. Order an abdominal ultrasound to rule out molar pregnancy
RATIONALE: Hyperemesis gravidarum is a severe form of nausea and vomiting of
pregnancy characterized by persistent vomiting, weight loss (> 5% of pre-
pregnancy weight), ketonuria, and electrolyte disturbances. This patient meets
criteria with her inability to tolerate oral intake, significant weight loss, and
ketonuria. When oral intake is not possible and there is evidence of dehydration
and metabolic disturbance, inpatient management with intravenous fluid
resuscitation, parenteral antiemetics, and electrolyte repletion is indicated.
• A: Prescribe oral ondansetron – Incorrect. The patient cannot tolerate oral
intake, making oral medications ineffective. She requires parenteral
therapy and fluid resuscitation.
• B: Recommend small meals and ginger – Incorrect. These are first-line
lifestyle interventions for mild nausea and vomiting of pregnancy, but they
are insufficient for hyperemesis gravidarum with dehydration and ketosis.
• D: Order abdominal ultrasound for molar pregnancy – Incorrect. While
hyperemesis can be associated with molar pregnancy, the immediate
priority is stabilizing the patient with fluids and antiemetics. Ultrasound
evaluation is appropriate but not the most urgent initial step.
4. A 35-year-old G3P2 at 16 weeks gestation undergoes maternal serum quad
screening. The results show: AFP 0.5 MoM (low), hCG 2.5 MoM (high), estriol 0.6
MoM (low), and inhibin A 2.0 MoM (high). Which of the following is the most
likely chromosomal abnormality?
A. Trisomy 21 (Down syndrome)
B. Trisomy 18 (Edwards syndrome)
C. Trisomy 13 (Patau syndrome)
D. Turner syndrome (45,X)
RATIONALE: The quad screen pattern of LOW AFP, LOW estriol, HIGH hCG, and
HIGH inhibin A is the classic biochemical signature associated with Trisomy 21
(Down syndrome). The combination of these four markers provides
approximately 80% detection rate for Down syndrome with a 5% false-positive
pg. 3
, 4
rate. This pattern reflects altered fetoplacental hormone production in
pregnancies affected by Trisomy 21.
• B: Trisomy 18 – Incorrect. Trisomy 18 is characterized by LOW levels of ALL
four markers: low AFP, low hCG, low estriol, and low inhibin A.
• C: Trisomy 13 – Incorrect. Trisomy 13 has no specific characteristic quad
screen pattern, though it may show slightly low AFP and estriol. It is often
associated with structural anomalies detected on ultrasound.
• D: Turner syndrome – Incorrect. Turner syndrome (45,X) is associated with
high hCG levels but normal or slightly low AFP, and estriol levels are
variably affected. The classic quad screen pattern is not seen.
5. A 24-year-old Rh-negative G2P1 at 28 weeks gestation presents for routine
prenatal care. Her antibody screen is negative. Which of the following is the
most appropriate next step in Rh alloimmunization prophylaxis?
A. Administer Rh immune globulin 300 mcg intramuscularly at 28 weeks
B. Administer Rh immune globulin only if the antibody screen becomes positive
C. Administer Rh immune globulin after delivery only if the newborn is Rh-positive
D. No intervention is needed as her antibody screen is negative
RATIONALE: Current ACOG guidelines recommend routine antenatal Rh immune
globulin (RhIg) prophylaxis for all Rh-negative pregnant women who are
unsensitized (negative antibody screen). The standard protocol is administration
of 300 mcg of RhIg at 28 weeks gestation. This dose provides passive immunity
and prevents maternal sensitization from silent fetomaternal hemorrhages that
occur during the third trimester. A second dose is given postpartum if the
newborn is confirmed Rh-positive.
• B: Administer only if antibody screen becomes positive – Incorrect. RhIg is
given to PREVENT sensitization, not after it has occurred. Once the antibody
screen is positive, RhIg is no longer effective.
• C: Administer after delivery only if newborn is Rh-positive – Incorrect.
While postpartum RhIg is essential, limiting prophylaxis to the postpartum
period misses the 1-2% of women who become sensitized during the third
trimester before delivery.
pg. 4
Barkley WHNP Comprehensive Board Review Exam
| 100 Questions and Verified Answers
Section 1: Obstetrics & Antepartum Care (Questions 1-25)
1. A 28-year-old G2P1 at 32 weeks gestation presents with a blood pressure of
150/95 mmHg and 2+ proteinuria on urine dipstick. She denies headache, visual
changes, or epigastric pain. Deep tendon reflexes are 3+ with mild clonus.
Which of the following is the most accurate classification of her condition?
A. Gestational hypertension
B. Chronic hypertension
C. Preeclampsia without severe features
D. Preeclampsia with severe features
RATIONALE: Preeclampsia is defined by new-onset hypertension (systolic ≥ 140
mmHg or diastolic ≥ 90 mmHg) after 20 weeks gestation with proteinuria or
evidence of end-organ dysfunction. Severe features include systolic BP ≥ 160
mmHg or diastolic BP ≥ 110 mmHg, thrombocytopenia (< 100,000/µL), impaired
liver function (transaminases > twice normal, severe RUQ/epigastric pain), renal
insufficiency (serum creatinine > 1.1 mg/dL or doubling of baseline), pulmonary
edema, or new-onset cerebral/visual disturbances. This patient's BP of 150/95
does not reach the severe threshold. While hyperreflexia and clonus are
concerning, they do not independently constitute severe features without the
above criteria.
• A: Gestational hypertension – Incorrect. This requires new-onset
hypertension after 20 weeks WITHOUT proteinuria. The presence of 2+
proteinuria moves the diagnosis to preeclampsia.
• B: Chronic hypertension – Incorrect. This is hypertension diagnosed before
pregnancy or before 20 weeks gestation. This patient's hypertension is new
after 20 weeks.
• D: Preeclampsia with severe features – Incorrect. Her blood pressure is
150/95, which does not meet the severe threshold of 160/110. She lacks
other severe features such as thrombocytopenia, elevated liver enzymes, or
pg. 1
,2
cerebral/visual symptoms. Clonus and hyperreflexia alone do not define
severe features.
2. A 32-year-old G1P0 at 28 weeks gestation presents with a 1-hour glucose
challenge test (GCT) result of 155 mg/dL. Which of the following is the most
appropriate next step?
A. Diagnose gestational diabetes mellitus and begin dietary counseling
B. Order a 3-hour 100-gram oral glucose tolerance test (OGTT)
C. Order a fasting blood glucose and hemoglobin A1c
D. Reassure the patient that the result is normal
RATIONALE: The 1-hour 50-gram glucose challenge test (GCT) is a screening test
for gestational diabetes mellitus (GDM). A value ≥ 130-140 mg/dL (depending on
institutional cutoffs) is considered a positive screen. This 155 mg/dL result
exceeds the common threshold of 130-135 mg/dL, indicating the need for
diagnostic testing. The definitive diagnostic test is the 3-hour 100-gram oral
glucose tolerance test (OGTT). GDM is diagnosed if two or more values on the
OGTT meet or exceed the Carpenter-Coustan criteria.
• A: Diagnose GDM and begin dietary counseling – Incorrect. The GCT is a
screening test, not diagnostic. A single elevated GCT alone is insufficient to
diagnose GDM; confirmatory testing is required.
• C: Order fasting glucose and A1c – Incorrect. While fasting glucose is
sometimes used in non-pregnant populations, the standard of care for
diagnosing GDM in pregnancy is the 3-hour OGTT. A1c is not validated for
diagnosing GDM.
• D: Reassure the patient the result is normal – Incorrect. A result of 155
mg/dL on the 1-hour GCT exceeds standard screening thresholds and
requires further evaluation.
3. A 26-year-old G1P0 at 10 weeks gestation presents with severe nausea and
vomiting, weight loss of 8 pounds, and ketonuria. She is unable to tolerate oral
intake. Which of the following is the most appropriate initial management?
A. Prescribe oral ondansetron and schedule a follow-up in 1 week
B. Recommend small, frequent meals and ginger supplementation
pg. 2
,3
C. Admit for intravenous fluids, antiemetics, and electrolyte monitoring
D. Order an abdominal ultrasound to rule out molar pregnancy
RATIONALE: Hyperemesis gravidarum is a severe form of nausea and vomiting of
pregnancy characterized by persistent vomiting, weight loss (> 5% of pre-
pregnancy weight), ketonuria, and electrolyte disturbances. This patient meets
criteria with her inability to tolerate oral intake, significant weight loss, and
ketonuria. When oral intake is not possible and there is evidence of dehydration
and metabolic disturbance, inpatient management with intravenous fluid
resuscitation, parenteral antiemetics, and electrolyte repletion is indicated.
• A: Prescribe oral ondansetron – Incorrect. The patient cannot tolerate oral
intake, making oral medications ineffective. She requires parenteral
therapy and fluid resuscitation.
• B: Recommend small meals and ginger – Incorrect. These are first-line
lifestyle interventions for mild nausea and vomiting of pregnancy, but they
are insufficient for hyperemesis gravidarum with dehydration and ketosis.
• D: Order abdominal ultrasound for molar pregnancy – Incorrect. While
hyperemesis can be associated with molar pregnancy, the immediate
priority is stabilizing the patient with fluids and antiemetics. Ultrasound
evaluation is appropriate but not the most urgent initial step.
4. A 35-year-old G3P2 at 16 weeks gestation undergoes maternal serum quad
screening. The results show: AFP 0.5 MoM (low), hCG 2.5 MoM (high), estriol 0.6
MoM (low), and inhibin A 2.0 MoM (high). Which of the following is the most
likely chromosomal abnormality?
A. Trisomy 21 (Down syndrome)
B. Trisomy 18 (Edwards syndrome)
C. Trisomy 13 (Patau syndrome)
D. Turner syndrome (45,X)
RATIONALE: The quad screen pattern of LOW AFP, LOW estriol, HIGH hCG, and
HIGH inhibin A is the classic biochemical signature associated with Trisomy 21
(Down syndrome). The combination of these four markers provides
approximately 80% detection rate for Down syndrome with a 5% false-positive
pg. 3
, 4
rate. This pattern reflects altered fetoplacental hormone production in
pregnancies affected by Trisomy 21.
• B: Trisomy 18 – Incorrect. Trisomy 18 is characterized by LOW levels of ALL
four markers: low AFP, low hCG, low estriol, and low inhibin A.
• C: Trisomy 13 – Incorrect. Trisomy 13 has no specific characteristic quad
screen pattern, though it may show slightly low AFP and estriol. It is often
associated with structural anomalies detected on ultrasound.
• D: Turner syndrome – Incorrect. Turner syndrome (45,X) is associated with
high hCG levels but normal or slightly low AFP, and estriol levels are
variably affected. The classic quad screen pattern is not seen.
5. A 24-year-old Rh-negative G2P1 at 28 weeks gestation presents for routine
prenatal care. Her antibody screen is negative. Which of the following is the
most appropriate next step in Rh alloimmunization prophylaxis?
A. Administer Rh immune globulin 300 mcg intramuscularly at 28 weeks
B. Administer Rh immune globulin only if the antibody screen becomes positive
C. Administer Rh immune globulin after delivery only if the newborn is Rh-positive
D. No intervention is needed as her antibody screen is negative
RATIONALE: Current ACOG guidelines recommend routine antenatal Rh immune
globulin (RhIg) prophylaxis for all Rh-negative pregnant women who are
unsensitized (negative antibody screen). The standard protocol is administration
of 300 mcg of RhIg at 28 weeks gestation. This dose provides passive immunity
and prevents maternal sensitization from silent fetomaternal hemorrhages that
occur during the third trimester. A second dose is given postpartum if the
newborn is confirmed Rh-positive.
• B: Administer only if antibody screen becomes positive – Incorrect. RhIg is
given to PREVENT sensitization, not after it has occurred. Once the antibody
screen is positive, RhIg is no longer effective.
• C: Administer after delivery only if newborn is Rh-positive – Incorrect.
While postpartum RhIg is essential, limiting prophylaxis to the postpartum
period misses the 1-2% of women who become sensitized during the third
trimester before delivery.
pg. 4
