EFM Certified - Electronic Fetal Monitoring Questions and Answers

Comprehensive and Detailed Explanation From Exact Extract (NCC C-EFM sources: AWHONN, Miller’s Pocket Guide, Menihan, Simpson, Creasy & Resnik, 2025 Candidate Guide)

AWHONN and Menihan emphasize that most fetal dysrhythmias detected intrapartum are premature atrial contractions (PACs)—the most common benign rhythm variation. They typically appear as intermittent, irregular deflections on the fetal heart rate tracing without affecting variability or baseline.

Miller’s Pocket Guide to Fetal Monitoring states that PACs are usually transient, self-limiting, and require only observation unless accompanied by tachyarrhythmia or hemodynamic compromise. When variability is preserved and no repetitive pattern or sustained tachycardia occurs, no intrauterine resuscitation measures are indicated.

Simpson and Creehan describe that oxygen administration and fluid boluses are not recommended for benign dysrhythmias, as they do not improve fetal conduction patterns and may contribute to unnecessary interventions.

The NCC 2025 Candidate Guide specifies that correct management requires distinguishing benign arrhythmias from pathologic tachyarrhythmias, which would require escalation. In the absence of fetal compromise or maternal pathology, the appropriate action is continued observation.

Therefore, the correct management is to continue to observe.

Comprehensive and Detailed Explanation From Exact Extract (No URLs or Links):

Early decelerations are defined in NCC and AWHONN resources as gradual, uniform decelerations that mirror uterine contractions and are associated with fetal head compression. AWHONN’s Fetal Heart Monitoring Principles states: “Early decelerations are a benign pattern caused by vagal stimulation secondary to fetal head compression.” Menihan similarly notes: “The mechanism of early decelerations is a vagal reflex response; they do not reflect hypoxia.”

They are periodic, not episodic, because they occur with contractions—which rules out option A.

They typically remain within a normal heart rate range and do not usually fall below 100 bpm; this eliminates option C. NCC Candidate Guide emphasizes that early decelerations are considered a normal physiologic response, not a pathologic pattern, and are categorized as “Category I” when variability is present.

Thus, the correct characteristic is that they are caused by a vagal reflex, making B the correct answer.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

NCC’s Professional Issues domain includes EMTALA obligations for pregnant patients. EMTALA requires that ANY individual who presents to a hospital emergency department—regardless of insurance status—must receive:

A Medical Screening Examination (MSE)

Stabilization of any identified emergency medical condition (including labor)

No transfer unless the patient requests it or the hospital cannot provide necessary stabilizing care

This patient reports contractions at 36 weeks, which qualifies as a potential emergency medical condition until ruled out by the medical screening exam.

Correct obligations per EMTALA:

She must NOT be transferred solely due to lack of insurance (option C).

She does NOT need to be admitted unless labor is confirmed (option A).

She must receive a medical screening examination and stabilization (option B).

Thus, the correct answer is B. Stabilized and receive a medical screening examination.

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

Sentinel events are defined by the Joint Commission as unexpected occurrences involving death, serious physical or psychological injury, or the risk thereof, and they require immediate investigation, root-cause analysis, and institutional response. They do not require confirmed malpractice or negligence.

AWHONN’s perinatal safety guidelines and NCC’s Professional Issues domain specify that sentinel events trigger mandatory reporting, analysis, system review, and corrective action plans. Simpson & Creehan emphasize that they are addressed through standardized safety processes, including interdisciplinary review.

Miller’s Pocket Guide notes that sentinel events are “events that require immediate investigation to prevent recurrence,” aligning with answer choice B.

Comprehensive and Detailed Explanation From Exact Extract (No URLs):

According to AWHONN Fetal Heart Monitoring Principles & Practice, Simpson & Miller, and the NCC C-EFM Content Outline, fetal heart rate categories are assigned based on baseline, variability, presence/absence of accelerations, and type of decelerations.

A Category II tracing includes any pattern that is not clearly normal (Category I) or clearly abnormal (Category III). Classic Category II features include:

• Bradycardia NOT accompanied by absent variability

• Tachycardia

• Minimal variability

• Marked variability

• Absence of accelerations after stimulation

• Recurrent variable decelerations with minimal or moderate variability

• Prolonged decelerations (≥2 min but <10 min)

In this tracing, the fetus demonstrates:

– A prolonged deceleration with subsequent recovery,

– Presence of baseline variability,

– Return toward baseline but not immediately normal.

AWHONN and Simpson state that any prolonged deceleration automatically places the tracing in Category II unless variability is absent (which would escalate it to Category III). Because variability is present, it cannot be Category III.

Therefore, by NCC standards, this tracing is Category II.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

This tracing demonstrates a normal, reassuring fetal heart pattern that is technically categorized as Category I, indicating normal fetal acid–base status. Before any decision regarding discharge or induction, NCC emphasizes correct assessment of the tracing quality, fetal status, and uterine activity.

Key Tracing Characteristics

Baseline:Approximately 135–145 bpm, well within the normal range of 110–160 bpm.

Variability:The strip shows moderate variability (6–25 bpm), the strongest indicator of adequate fetal oxygenation per NCC, AWHONN, and NICHD.

Accelerations:Several accelerations are present—another reassuring feature of normal fetal well-being.

Decelerations:No variable, late, or prolonged decelerations are present.

Uterine Activity:The lower channel shows poor recording quality and inconsistent signal—suggesting the toco is not capturing contractions well, not that the patient is contracting excessively or not at all.

Correct interpretation per NCC:

NCC emphasizes distinguishing between physiologic assessment and technical artifact.

The fetal tracing is completely reassuring.

The only abnormality is the poor uterine activity signal, a common triage occurrence due to:

Toco placement

Maternal body habitus

Positioning

Low contraction intensity in early labor

Thus, the correct next step is to optimize equipment (reposition the toco, adjust belt, palpate contractions) and continue to monitor.

Why the other options are incorrect:

B. Admit for induction – NOT indicated

There is no evidence of fetal compromise.

No indication for induction is present (pain score 4/10, reassuring FHR, term pregnancy).

NCC emphasizes avoiding unnecessary interventions.

C. Discharge to home – NOT yet appropriate

You cannot safely discharge a patient with a poorly monitored contraction pattern.

Adequate assessment requires confirming uterine activity—after fixing the toco.

Therefore, the appropriate action is:

A. Adjust tocotransducer and continue to monitor.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

The tracing shows significant artifact, periods of signal loss, and abrupt changes inconsistent with physiologic fetal patterns. This is typical of poor signal quality, not actual fetal decelerations. In early labor at –2 station, external FHR monitoring often loses contact due to fetal position and maternal movement.

NCC and AWHONN emphasize the following when artifact is present:

Correct signal quality before interpreting the tracing.

Troubleshooting steps include:– Adjusting transducer location– Ensuring adequate ultrasound gel– Repositioning the mother– Checking for maternal heart rate contamination

Why the other options are incorrect:

B. IV fluid bolus — Indicated for hypotension or late decelerations, not for artifact.

C. Terbutaline — Used for tachysystole with fetal intolerance; there is no tachysystole shown.

Thus, the correct first step is A. Adjust the fetal monitor.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

Amnioinfusion is considered an intrauterine resuscitative intervention used specifically for recurrent variable decelerations caused by cord compression. NCC, AWHONN, Miller, and Menihan consistently teach that variables occur when the umbilical cord becomes compressed, reducing fetal oxygenation. When oligohydramnios or decreased amniotic fluid volume is present, the cord is more vulnerable to compression.

Why amnioinfusion is used:

Amnioinfusion works by:

Increasing intraamniotic fluid volume

Reducing umbilical cord compression

Decreasing the frequency and severity of variable decelerations

This directly targets the pathophysiology behind recurrent variables.

Why the other options are incorrect:

A. Dilute thick meconium – NOT supported by NCC

Historically, amnioinfusion was studied for meconium dilution, but major organizations—including NCC-aligned sources—state that amnioinfusion is NOT recommended for the sole purpose of diluting meconium. It does not reduce meconium aspiration syndrome and is no longer indicated for that purpose.

B. Restore uterine blood flow – NOT accurate

Uterine blood flow is addressed through maternal positioning, fluid bolus, reducing uterine tachysystole, and minimizing vasoconstriction—not via amnioinfusion. Amnioinfusion does not physiologically affect uterine perfusion.

C. Treat oligohydramnios – CORRECT

Recurrent variables with thick meconium often occur in the setting of low fluid, which worsens cord compression.

NCC-recommended indications include:

Recurrent variable decelerations unresponsive to repositioning

Suspected or confirmed oligohydramnios

Thick meconium may be associated with low fluid, but the purpose of amnioinfusion is to alleviate cord compression by restoring fluid volume, not to dilute the meconium.

Thus, the correct answer is C. Treat oligohydramnios.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Placental calcifications:

Reduce surface area for maternal–fetal gas exchange

Impair placental perfusion

Are associated with post-dates and chronic insufficiency

Decrease the placenta’s ability to oxygenate the fetus

Why the incorrect answers are wrong:

A. Increased maternal cardiac output → improves uteroplacental perfusion.

B. Open-glottis pushing → improves oxygenation compared with closed-glottis Valsalva pushing.

Correct answer: Placental calcifications.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Contraction duration is defined as the length of time from the beginning of a contraction to the end of the same contraction (NICHD uterine activity definitions).

In the diagram:

Green arrow (B) spans one individual contraction from rise → peak → return to baseline.

Blue arrow (A) measures the interval between contractions (frequency).

Red arrow (C) measures peak-to-peak amplitude shape, not duration.

Therefore, the green arrow correctly identifies contraction duration.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

Accurate classification of decelerations requires evaluating their shape, onset, nadir, recovery, relationship to contractions, and variability characteristics. NCC uses the NICHD standardized definitions, reinforced across AWHONN, Miller’s Pocket Guide, Menihan, Simpson, and Creasy & Resnik.

Key features in this tracing:

Abrupt onsetThe FHR drops rapidly from baseline to nadir in less than 30 seconds—this is the defining hallmark of a variable deceleration per NICHD.

Sharp V-shape and deep amplitudeThe tracing shows steep descents and ascents, characteristic of cord compression–type variable decelerations.

Inconsistent timing with contractionsThe decelerations do not begin at the start of contractions (as early decelerations would) and do not consistently begin after the peak of contractions (as late decelerations would). Variable decelerations can occur before, during, or after a contraction—exactly what is demonstrated here.

Rapid return to baselineAnother core feature of variable decelerations in NICHD/NCC definitions.

No uniform contraction relationshipEarly decelerations are symmetrical and mirror contractions. Late decelerations begin after the peak of the contraction. This strip does not match either pattern.

Differentiation per NCC-aligned definitions:

Early Decelerations:Gradual onset (>30 sec), nadir mirrors contraction peak, shallow, uniform.Not present.

Late Decelerations:Gradual descent, nadir after contraction peak, smooth shape.Not present.

Variable Decelerations:Abrupt onset (<30 sec), variable timing, sharp V-shape, rapid recovery, often with shoulders.Exactly matches the tracing.

Therefore, according to NICHD/NCC criteria, the decelerations shown are variable decelerations.

Comprehensive and Detailed Explanation From Exact Extract without any URL or Links

According to the NCC C-EFM 2025 Candidate Guide, Pattern Recognition and Intervention requires the candidate to classify fetal heart rate (FHR) patterns using the NICHD 2008 three-tier system, which NCC endorses across all recommended resources (AWHONN Fetal Heart Monitoring Principles and Practices, Menihan Electronic Fetal Monitoring, Simpson & Creasy, Miller’s Pocket Guide).

A Category II tracing is defined as “indeterminate” and includes any FHR pattern that is not Category I and not Category III. NCC references indicate that Category II may include:

Minimal or marked variability

Absence of accelerations after fetal stimulation

Recurrent variable decelerations with moderate variability

Prolonged decelerations lasting 2–10 minutes

Baseline tachycardia or bradycardia without absent variability

In the tracing provided:

The baseline FHR is approximately 135–145 bpm, within normal limits.

Moderate variability is not consistently present; variability is borderline minimal–moderate at times.

No significant accelerations are seen over the 25-minute evaluation period.

No recurrent late or prolonged decelerations are present.

There are occasional subtle variable-type dips, but not enough to meet criteria for Category III.

NCC-endorsed texts (such as AWHONN and Menihan) state that a tracing with minimal variability for less than 40 minutes and without recurrent decelerations is Category II, as it fails to meet the requirements for Category I (must have moderate variability and accelerations absent decelerations) and lacks the criteria for Category III (must have absent variability with recurrent late decels, recurrent variable decels, bradycardia, or sinusoidal pattern).

Therefore, this pattern is indeterminate, consistent with Category II, and requires continued surveillance and evaluation, which aligns with NCC-recommended clinical decision-making competencies.

Comprehensive and Detailed Explanation From Exact Extract Without Any URLs or Links:

NCC references (AWHONN, Simpson, Menihan) and the Physiology domain emphasize that baseline fetal heart rate is higher at earlier gestational ages due to predominant sympathetic tone and immature parasympathetic modulation. For a 28-week fetus, a baseline between 150–170 bpm may fall within the upper normal/mild tachycardic range.

Before classifying fetal tachycardia, recommended by AWHONN and Simpson, clinicians must first assess maternal contributors:

Fever

Tachycardia

Infection

Dehydration

Medications (e.g., beta-agonists)

Anxiety

This matches NCC’s required first-line action: evaluate maternal status before escalating fetal assessment.

A biophysical profile (BPP) is not the immediate next step unless maternal status and fetal environment do not explain the finding. Continuing observation without maternal evaluation is contrary to perinatal safety standards.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

NCC and NICHD define baseline FHR as the mean FHR rounded to increments of 5 bpm during a minimum of a 10-minute window, excluding:

Accelerations

Decelerations

Marked variability

If a segment shorter than 10 minutes is used, it cannot be called a "baseline".

Thus the required minimum is 10 minutes.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

The fetal heart rate tracing demonstrates recurrent deep variable decelerations with a rapid drop in FHR, a V-shaped pattern, and slow return to baseline. These are classic signs of cord compression. According to NCC, AWHONN, Miller, Menihan, and Simpson, recurrent variable decelerations require immediate intrauterine resuscitative interventions before any decision regarding operative birth.

NCC-aligned intervention steps include:

Maternal repositioning (first-line for cord compression)

Reducing or stopping oxytocin if infusing

IV fluid bolus

Amnioinfusion (if appropriate and recurrent deep variables persist)

Oxygen only if other measures fail (per NCC/AWHONN updated guidance)

The cervix has remained unchanged at 5 cm for 3 hours (a prolonged latent or early active labor pattern), but the fetal tracing shows Category II—recurrent variable decelerations. Category II dictates corrective action, not immediate delivery unless it progresses to Category III.

Cesarean birth (option C) is reserved for:

Persistent Category III

Failure of intrauterine resuscitation

Proven fetal intoleranceNone of these conditions have been met yet.

Thus, the correct initial management is B. Perform intrauterine resuscitative measures.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

This tracing demonstrates:

A sudden prolonged deceleration following epidural placement

Minimal variability during the deceleration

Event occurring within 15 minutes of epidural

NCC, AWHONN, and Menihan emphasize that maternal hypotension is the most common complication immediately following epidural analgesia. Hypotension leads to:

Reduced uteroplacental perfusion

Fetal bradycardia or prolonged decelerations

Decreased variability during the deceleration

Typical fetal response to maternal hypotension:

Late-like or prolonged deceleration with weakening variability, exactly like the strip shown.

Therefore, the FIRST and most critical step is to check maternal blood pressure.

Other options:

B. Continue to monitor — unsafe when a prolonged deceleration is present.

C. Cervical exam — not indicated; the fetal tracing deterioration is temporally linked to epidural placement.

Thus, the correct action is A. Check maternal blood pressure.

Comprehensive and Detailed Explanation From Exact Extract Without Links:

NCC and AWHONN teaching materials describe that butorphanol, an opioid analgesic, characteristically produces a transient sinusoidal-like pattern or pseudo-sinusoidal pattern with moderate variability preserved.

This drug-related pattern has:

• smooth, regular oscillations

• maintained variability

• absence of true periodic decelerations

• resolution within 20–60 minutes

Simpson & Menihan describe butorphanol as producing a “saw-tooth, wavering pattern” often mistaken for dysrhythmia but actually benign.

True sinusoidal patterns (e.g., fetal-maternal hemorrhage) are fixed, smooth, non-variable patterns with absent variability, not matching the scenario.

Atrial flutter produces very rapid atrial contractions, which manifest as irregular baseline spikes—also not consistent.

Therefore, the described tracing aligns most closely with butorphanol effects.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

When bright red vaginal bleeding occurs at the moment of membrane rupture, accompanied by an acute, severe fetal heart rate deterioration, NCC sources emphasize considering conditions causing fetal hemorrhage rather than maternal instability.

The key features in this scenario:

Timing:Bleeding occurs immediately with spontaneous rupture of membranes—this is classic for vasa previa rupture, where fetal vessels traverse membranes and are torn when the membranes rupture.

Bleeding characteristics:Bleeding is acute, bright red, and sudden.In vasa previa, the blood observed vaginally is fetal blood, not maternal blood.

Uterine exam:The uterus is soft and nontender, which strongly argues against abruptio placenta, where the uterus is typically firm, rigid, or painful.

Maternal vital signs:Maternal blood pressure and pulse are normal, indicating no maternal hypovolemia.In placental abruption or placenta previa with significant maternal bleeding, maternal vitals are often abnormal.Here, the mother is stable, meaning the blood is not maternal—supporting fetal vessel rupture.

Fetal heart rate pattern:

Initial tachycardia, followed by

Bradycardia with minimal variabilitySuch a pattern is consistent with acute fetal blood loss, which rapidly leads to fetal hypovolemia and hypoxia.

Differential based on NCC-aligned physiology:

A. Abruptio placenta – NOT supported

Typically presents with:

Painful bleeding

Firm, tender uterus

Maternal tachycardia

Uterine irritabilityNone of these are present.

B. Placenta previa – NOT supported

Classically painless bright red bleeding before or early in labor, not triggered by membrane rupture.

Fetal compromise is less sudden unless maternal shock occurs, which is not the case here.

C. Ruptured vasa previa – CORRECT

Defined by:

Painless, sudden bright red bleeding at ROM

Normal maternal vital signs

Rapid fetal deterioration (tachycardia → bradycardia → minimal variability)

Soft, nontender uterusThis fits the scenario exactly.

Therefore, the most likely cause is ruptured vasa previa, a recognized obstetric emergency described across AWHONN, NCC C-EFM references, and maternal–fetal physiology texts such as Menihan and Creasy & Resnik.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The NST strip shows:

Baseline FHR about 140 bpm

Moderate variability

Two or more accelerations meeting 15×15 criteria

No decelerations

Normal, infrequent contractions

Per NCC and AWHONN, a reactive NST is defined as:

≥2 accelerations of 15 bpm × 15 seconds in a 20-minute period

With baseline 110–160 and moderate variability

No recurrent decelerations

A reactive NST at 36 weeks in a hemodynamically stable mother with normal vitals is reassuring, and the appropriate disposition is routine follow-up and discharge.

Why the other options are incorrect:

B. Induce labor – Not indicated solely on maternal age or a reactive NST.

C. Kleihauer-Betke test – Used to quantify fetomaternal hemorrhage after trauma or sensitization risk; there is no such history here.

Therefore, the correct action is A. Discharge home.

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

The tracing demonstrates a baseline within normal limits, moderate variability, and recurrent variable decelerations associated with contractions. According to NICHD/NCC definitions reproduced in AWHONN’s Fetal Heart Monitoring Principles & Practices and Menihan’s Electronic Fetal Monitoring, recurrent variable decelerations with preserved variability classify the tracing as Category II.

A Category I pattern must show baseline 110–160, moderate variability, and absence of late or variable decelerations. Because this tracing shows recurrent variable decelerations, it does not meet Category I criteria.

Category III requires absent variability PLUS recurrent late decelerations, recurrent variable decelerations, bradycardia, or a sinusoidal pattern. This tracing shows moderate variability, therefore it cannot be Category III.

Simpson & Creehan emphasize that variable decelerations reflect cord compression and fall into Category II unless accompanied by absent variability. Miller’s Pocket Guide confirms that moderate variability maintains fetal compensatory reserve, keeping the pattern in Category II.

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

Fetal tachycardia is typically caused by maternal fever, dehydration, hypoxia, medications, infection, or fetal stress. AWHONN and Simpson & Creehan emphasize that management focuses on improving oxygen delivery across the placenta, which is governed by uteroplacental perfusion.

Menihan’s EFM text states that “interventions for fetal tachycardia must address oxygen transfer by optimizing uteroplacental blood flow,” including hydration, reducing uterine activity, maternal repositioning, and treating maternal fever.

Increasing maternal circulation alone is insufficient unless it improves placental blood flow. Enhancing fetal sympathetic tone is not a clinical goal and would worsen tachycardia.

Creasy & Resnik highlight that fetal heart rate abnormalities resolve when uteroplacental perfusion is restored, confirming this as the primary target of intervention.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The black tracing (Baby A) demonstrates:

Baseline ~170–175 bpm

Moderate variability

No recurrent decelerations

This is fetal tachycardia.

NCC physiology guidelines list common causes of fetal tachycardia:

Maternal fever / infection (chorioamnionitis)

Maternal dehydration

Maternal anxiety

Maternal hyperthyroidism

Fetal infection

Certain medications (terbutaline, illicit stimulants)

Why the other options are incorrect:

A. Fetal positioning does not influence baseline heart rate.

C. Magnesium sulfate typically lowers fetal baseline and variability—it does not cause tachycardia.

Thus, the most likely etiology is infection.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

NCC and AWHONN emphasize unit-wide shared responsibility for:

Recognizing abnormal maternal or fetal findings

Calling for help

Triggering emergency responses (e.g., unit huddle, rapid response, safety pathways)

Safety culture requires:

Any staff member (RN, tech, provider) to initiate an alarm or escalate concern

No hierarchy delay

Rapid action when fetal compromise is suspected

Why the other answers are wrong:

A. Determined by unit leaders → incorrect; safety is team-wide, not hierarchical.

C. Occur infrequently → false; alarms must occur whenever needed, not limited.

Correct answer: B. Can be called by anyone.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

NICHD definitions endorsed by NCC:

An acceleration lasting ≥10 minutes is no longer an acceleration

It is classified as a baseline change

This also applies to decelerations lasting ≥10 minutes being considered a new baseline bradycardia

Why the incorrect answers are wrong:

B. Baseline variability → refers to amplitude fluctuations, not duration.

C. Tachycardia → requires baseline >160 bpm for 10 minutes, but the definition of “acceleration ≥10 minutes = baseline change” supersedes this.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

When evaluating an admission tracing, NCC emphasizes determining whether the pattern represents baseline variability abnormalities, signal artifact, or an underlying fetal cardiac rhythm disturbance. The strip shown contains clear features of a fetal dysrhythmia, which NCC and AWHONN describe as an irregular rhythm characterized by inconsistent R–R intervals or intermittent missed beats.

Key features in this tracing:

Extremely irregular FHR signalThe pattern shows abrupt vertical spikes, inconsistent spacing, and intermittent loss of coherent waveform. NCC teaches that this appearance is typical of irregular ventricular conduction or premature atrial/ventricular contractions.

Wide variability in beat spacingBeat intervals vary significantly, suggesting ectopic beats or conduction abnormalities rather than a stable rhythm such as heart block or atrial flutter.

Sensor not malfunctioningThe lower uterine activity channel is smooth and consistent, meaning the upper channel’s abrupt changes represent true FHR signal irregularity, not artifact.

Why the incorrect answers are ruled out:

A. Atrial flutter – NOT supported

Atrial flutter produces a very fast, regular atrial rate (typically 300 bpm) with a repetitive saw-tooth pattern.

It does not produce the highly irregular beat-to-beat pattern seen here.

FHR in atrial flutter appears more organized, not chaotic.

B. Complete heart block – NOT supported

Complete heart block (third-degree AV block) produces a very slow, regular ventricular rate, commonly 50–70 bpm, with a dissociation between atrial and ventricular rhythms.

The tracing here does not show a slow, steady baseline.

Instead, the rhythm is highly irregular with spikes and losses—not characteristic of AV block.

C. Fetal dysrhythmia – CORRECT

NCC, AWHONN, Miller, and Menihan describe fetal dysrhythmias as:“Irregular, inconsistent FHR patterns due to premature atrial contractions (PACs), premature ventricular contractions (PVCs), or intermittent conduction disturbances.”

The hallmark is an irregular rhythm, often appearing as abrupt spikes or missing beats on the monitor.

The tracing shown matches these characteristics precisely.

Therefore, the tracing is most consistent with fetal dysrhythmia, typically benign PACs/PVCs, and is the correct answer.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

The tracing shows tachysystole (more than 5 contractions in 10 minutes) with minimal variability and recurrent decelerations consistent with uteroplacental insufficiency caused by excessive uterine activity.

Dinoprostone (Cervidil) is a uterotonic prostaglandin, and one of its known complications is uterine tachysystole with Category II or III fetal heart rate patterns.

NCC/AWHONN guidance for tachysystole caused by prostaglandins:

FIRST intervention: Remove the dinoprostone insert.

Reposition the patient (already done).

IV fluid bolus (already done).

Consider terbutaline only if tachysystole persists after removal of the agent.

Since maternal repositioning and IV fluids have already failed, the next step is to remove the cervical ripening agent.

Why other answers are incorrect:

A. Continue to observe — Never acceptable with tachysystole + fetal intolerance.

B. Terbutaline — May be used after prostaglandin removal, not before.

Thus, the correct answer is C. Remove the dinoprostone insert.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

Accurate classification of decelerations requires evaluating their shape, onset, nadir, recovery, relationship to contractions, and variability characteristics. NCC uses the NICHD standardized definitions, reinforced across AWHONN, Miller’s Pocket Guide, Menihan, Simpson, and Creasy & Resnik.

Key features in this tracing:

Abrupt onsetThe FHR drops rapidly from baseline to nadir in less than 30 seconds—this is the defining hallmark of a variable deceleration per NICHD.

Sharp V-shape and deep amplitudeThe tracing shows steep descents and ascents, characteristic of cord compression–type variable decelerations.

Inconsistent timing with contractionsThe decelerations do not begin at the start of contractions (as early decelerations would) and do not consistently begin after the peak of contractions (as late decelerations would). Variable decelerations can occur before, during, or after a contraction—exactly what is demonstrated here.

Rapid return to baselineAnother core feature of variable decelerations in NICHD/NCC definitions.

No uniform contraction relationshipEarly decelerations are symmetrical and mirror contractions. Late decelerations begin after the peak of the contraction. This strip does not match either pattern.

Differentiation per NCC-aligned definitions:

Early Decelerations:Gradual onset (>30 sec), nadir mirrors contraction peak, shallow, uniform.Not present.

Late Decelerations:Gradual descent, nadir after contraction peak, smooth shape.Not present.

Variable Decelerations:Abrupt onset (<30 sec), variable timing, sharp V-shape, rapid recovery, often with shoulders.Exactly matches the tracing.

Therefore, according to NICHD/NCC criteria, the decelerations shown are variable decelerations.

Comprehensive and Detailed Explanation From Exact Extract Sources:

In fetal physiology, the highest oxygen saturation exists in the umbilical vein, which then flows through the ductus venosus before entering the right atrium.

According to Creasy & Resnik Maternal-Fetal Medicine, and AWHONN physiologic foundations:

The umbilical vein carries oxygen-rich blood from the placenta (approx. 80% saturation).

Most of this blood bypasses the liver via the ductus venosus, which therefore contains the most highly oxygenated blood within the fetal circulatory system.

By contrast:

The descending aorta contains mixed blood with significantly lower oxygen content due to mixing after passage through the ductus arteriosus.

The pulmonary arteries in the fetus carry predominantly deoxygenated blood, since fetal lungs are fluid-filled and have high pulmonary vascular resistance.

Thus, the structure containing the highest fetal oxygen concentration is the ductus venosus.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The tracing shows the classic features of variable decelerations:

Abrupt onset (<30 seconds from baseline to nadir)

Rapid drop followed by a rapid recovery

Significant variability in shape, depth, and timing

“Shouldering”—brief accelerations before or after the deceleration, typical of cord compression

The decelerations vary in appearance and timing relative to contractions

In second stage, this pattern is extremely common due to:

Recurrent cord compression during descent

Maternal pushing

Reduced amniotic fluid with advancing labor

Why the other options are incorrect:

A. Intermittent late decelerations

Late decelerations are uniform, smooth, begin after the contraction peak, and recover after the contraction ends.

This tracing shows abrupt, variable-shaped, non-uniform decels → NOT late decels.

C. Wandering baseline

A wandering baseline is a slowly fluctuating, low-amplitude, smooth, preterminal pattern.

This tracing shows an identifiable baseline with variability and clear decelerations, not wandering baseline.

Thus, the tracing is most consistent with variable decelerations.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Because the fetal myocardium is immature, it has:

Limited ability to increase stroke volume

Limited ability to increase contractility

Therefore, fetal cardiac output (CO) is almost entirely dependent on heart rate.

NCC and AWHONN physiology describe:

CO = stroke volume × heart rate

In the fetus, stroke volume is relatively fixed

Therefore, changes in HR directly affect cardiac output

Tachycardia → increases CO

Bradycardia → decreases CO → decreased perfusion and oxygen delivery

Why the other options are incorrect:

A. Activity does not fundamentally determine CO.

B. Baroreceptors regulate HR reflexively but are not the primary determinant of cardiac output.

Correct answer: C. Heart rate

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

An early deceleration is defined by NICHD and NCC as a gradual decrease and return of the fetal heart rate associated with uterine contractions. NCC emphasizes that early decelerations are:

Symmetrical

Uniform in shape

Mirror images of the contraction

This means:

Onset of deceleration = onset of contraction

Nadir of deceleration = peak of contraction

Recovery = end of contraction

Duration of the deceleration ≈ duration of the contraction

Thus, the correct answer is C. The same.

Comprehensive and Detailed Explanation From Exact Extract (No URLs or Links)

NCC-recommended physiologic texts (AWHONN, Menihan, Simpson, Creasy & Resnik) explain that variable decelerations are caused by umbilical cord compression. This process occurs in a three-step sequence, well known in fetal monitoring physiology:

Umbilical vein occlusion occurs first → decreases fetal venous return → brief fetal acceleration (a compensatory sympathetic response).

Umbilical artery occlusion follows → increases fetal systemic vascular resistance → variable deceleration as vagal stimulation lowers the fetal heart rate.

Release of compression → post-deceleration acceleration may occur.

Thus, an acceleration immediately before a variable deceleration represents the initial compression of the umbilical vein, not a hypoxic response. This is a normal physiologic response to transient cord compression, often described in AWHONN and Menihan's physiologic explanation of “shoulders” around variable decelerations.

Oligohydramnios can contribute to cord compression but does not explain accelerations preceding the deceleration. A “hypoxic reflex” would not produce a pre-deceleration acceleration.

Therefore, the correct physiologic cause is:

Umbilical vein occlusion.

References (No URLs)

NCC C-EFM Candidate Guide 2025 – Physiology

AWHONN Fetal Heart Monitoring Principles

Menihan: Electronic Fetal Monitoring

Simpson & Creehan: Perinatal Nursing

Creasy & Resnik: Maternal–Fetal Medicine

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

NCC and AWHONN consider fetal movement counts normal when:

≥10 distinct movements occur within 2 hours

Or ≥4 movements in 1 hour for certain protocols

Or ≥10 movements in 1 hour (common triage threshold)

This patient reports 12 movements in 1 hour, which is reassuring and requires no further testing.

Thus, recommending she continue daily kick counts at home is appropriate.

Why the other options are incorrect:

A. NST is not needed because movements are normal.

B. Continue to monitor is unnecessary; the test is already reassuring.

Correct choice: C. Count again the next day.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References:

NICHD/NCC definitions:

Prolonged deceleration: decrease in FHR ≥15 bpm lasting 2 to 10 minutes

Bradycardia: baseline FHR <110 bpm lasting ≥10 minutes

The differentiating factor is duration, not rate and not contraction relationship.

Before 10 minutes → prolonged deceleration

At or beyond 10 minutes → new baseline → bradycardia

Thus, the factor that differentiates the two is length of time it lasts.