EFM Certified - Electronic Fetal Monitoring Questions and Answers

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References (No URLs):

Interpretation of fetal heart rate (FHR) tracings in the NCC C-EFM exam follows the standardized NICHD three-tier classification, which is fully adopted in NCC’s content outline and recommended references such as AWHONN Fetal Heart Monitoring Principles & Practices, Miller’s EFM Pocket Guide, Menihan, Simpson’s Perinatal Nursing, and Creasy & Resnik.

Baseline:

The tracing demonstrates an FHR baseline around 145–150 bpm, which falls within the normal range of 110–160 bpm. NCC references define baseline as the mean FHR rounded to increments of 5 bpm over a 10-minute window.

Variability:

The strip shows minimal variability, with amplitude fluctuations approximately 0–2 bpm.

According to NCC-aligned definitions:

Moderate variability: 6–25 bpm

Minimal variability: 1–5 bpm

Absent variability: undetectable amplitude

This tracing shows minimal variability, not moderate, so it cannot be Category I.

Accelerations:

No accelerations are present. Lack of accelerations alone does not classify the tracing as Category III.

Decelerations:

There are no recurrent late decelerations, no recurrent variable decelerations, and no prolonged decelerations. Without these, and with minimal variability, the tracing does not meet Category III criteria.

Category III criteria (per NICHD/NCC):

Must include at least one of the following:

Absent variability with recurrent late decelerations

Absent variability with recurrent variable decelerations

Absent variability with bradycardia

Sinusoidal pattern

None of these are present.

Category II criteria (per NICHD/NCC):

Category II includes tracings that are not Category I or III.

Examples specifically listed include:

Minimal variability

Absent accelerations after fetal stimulation

Tachycardia

Bradycardia without absent variability

Variable or late decelerations occurring intermittently

Because this tracing shows minimal variability, a normal baseline, no accelerations, and no recurrent decelerations, it fits squarely into Category II.

Therefore, the correct classification is Category II.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

NICHD Category II includes:

Minimal variability

Marked variability

Absent accelerations without recurrent decelerations

Indeterminate baseline characteristics

A tracing with no accelerations and no decelerations becomes Category II if paired with marked variability, because marked variability indicates potential stress.

Why other answers are wrong:

A. FHR 110 bpm → normal baseline if variability normal.

B. Sinusoidal pattern → Category III, not Category II.

Correct answer: Marked variability.

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

When internal monitoring continues to record artifact despite:

Changing the scalp electrode

Ensuring correct attachment

Checking cable connections

Confirming maternal movement is not the cause

NCC requires confirmation of fetal well-being using another modality.

The correct next step is direct auscultation with Doppler or fetoscope.

Why other answers are incorrect:

Oxygen is not indicated for equipment malfunction.

Repositioning does not resolve internal FHR artifact.

Thus, Auscultate the fetal heart rate is the appropriate next step.

Comprehensive and Detailed Explanation From Exact Extract Without Links:

According to the NCC C-EFM Content Outline and AWHONN Fetal Heart Monitoring Principles, recurrent decelerations are specifically defined as decelerations that occur with ≥50% of uterine contractions in a 20–30-minute window, but standardized interpretation guidelines used by NCC and ACOG categorize recurrent patterns based on any 30-minute evaluation period.

AWHONN (FHM 6th Ed.) explains that fetal heart patterns must be evaluated over “a sufficiently long segment, typically 30 minutes, to determine whether the pattern is intermittent or recurrent.”

Menihan & Simpson further emphasize that recurrent decelerations imply a persistent physiologic stressor, requiring systematic evaluation and intrauterine resuscitation. NCC's Candidate Guide ties this rule directly into categorization within Category II and III tracings. Therefore, 30 minutes is the correct standard evaluation interval for determining recurrence.

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Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Tachysystole = >5 contractions in 10 minutes averaged over 30 minutes (NICHD).

However, NCC and AWHONN intervention guidelines state:

If tachysystole appears in one or two consecutive 10-minute segments, especially with Category II or III patterns, intervention must begin immediately.

Intervention includes:

Stopping/reducing oxytocin

Maternal repositioning

IV bolus

Tocolysis if needed

Why the wrong answers are wrong:

A. Waiting 30 minutes delays necessary fetal resuscitation.

C. Stage of labor does not determine when to intervene.

Correct answer: B. If tachysystole is seen for one or two 10-minute segments

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:

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 URLs or Links:

According to the NCC C-EFM 2025 Exam Content Outline and recommended references such as AWHONN Fetal Heart Monitoring Principles, Simpson & Miller (Fetal Monitoring Text), and Menihan’s EFM Guide, recurrent variable or late decelerations with minimal or moderate variability during the second stage of labor—particularly when the patient has been pushing for ≥2 hours—indicate progressive fetal intolerance of labor.

AWHONN states that when the fetal tracing displays recurrent variable decelerations with ongoing stress from long second stage, the recommended intervention is operative or expedited vaginal birth, provided the fetal station is at +2 or lower. AWHONN and Simpson emphasize that reducing oxytocin is insufficient when the tracing demonstrates ongoing significant decelerations during active pushing with adequate descent.

The NCC blueprint within Pattern Recognition & Intervention emphasizes:

Identifying worsening recurrent decelerations

Acting when fetal tolerance is decreasing

Prioritizing timely intervention when the second stage exceeds standard limits with a non-reassuring tracing

Because she is fully dilated, vertex at +2, and tracing shows recurrent decelerations during pushing, the evidence-based next step is expediting birth, typically via operative vaginal delivery.

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 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:

Evaluation of a tracing during oxytocin induction requires analysis of fetal status (baseline, variability, accelerations, decelerations) and uterine activity, with attention to tachysystole and fetal intolerance. NCC, AWHONN, Miller, Menihan, Simpson, and the NICHD guidelines all emphasize that oxytocin must be adjusted based on fetal response and contraction frequency.

Baseline:

The fetal heart rate baseline is approximately 150 bpm, which is within the normal range of 110–160 bpm.

Variability:

The tracing shows minimal variability (approximately 1–4 bpm amplitude). Minimal variability for a sustained period is categorized as a Category II pattern under NCC/NICHD classification.

Accelerations:

No accelerations are present during the 20-minute representative segment.

Decelerations:

There are no recurrent variable, no recurrent late, and no prolonged decelerations.

Uterine Activity:

The tracing shows very frequent contractions—approximately every 1½ to 2 minutes, which meets the NCC definition of tachysystole when averaged over 10 minutes (more than 5 contractions in 10 minutes).

According to NCC and AWHONN standards, when tachysystole is present with minimal variability, oxytocin must be reduced or discontinued even in the absence of late decelerations.

Clinical decision-making (per NCC principles):

NCC emphasizes that management of Category II patterns during induction starts with intrauterine resuscitative measures, including decreasing or stopping oxytocin when uterine activity is excessive or fetal response is suboptimal. Minimal variability with tachysystole requires correction of uterine stimulation before escalating to invasive monitoring or considering operative birth.

Option B (place a spiral electrode) is not indicated because the pattern is clearly visible and the priority is correcting uterine overstimulation, not refining the tracing.

Option C (operative birth) is not indicated; there is no Category III pattern or recurrent decelerations.

Option A (discontinue oxytocin) is the correct first-line action according to NCC-aligned guidelines when tachysystole and minimal variability occur.

Comprehensive and Detailed Explanation From Exact Extract Sources:

The tracing demonstrates an abrupt-onset, sharp, V-shaped deceleration, occurring simultaneously with or slightly after a contraction—classic for variable decelerations, which are caused by umbilical cord compression.

According to AWHONN Fetal Heart Monitoring Principles & Practices, variable decelerations are defined by:

“Abrupt decreases in FHR below baseline of at least 15 bpm, lasting at least 15 seconds and less than 2 minutes.”

“Most commonly associated with umbilical cord compression, whether transient or recurrent.”

Physiology reference (Simpson & Miller, Pocket Guide):

Compression of the umbilical vein causes a brief acceleration.

Compression of the umbilical arteries triggers a vagal response, producing a rapid deceleration.

This creates the characteristic sharp ‘V’, ‘U’, or ‘W’ shape on the monitor.

Placental insufficiency (Choice B) produces late decelerations, which are gradual, not abrupt.

Fetal head compression (Choice A) produces early decelerations, which mirror contractions and have a gradual pattern.

Thus, the tracing is most consistent with variable decelerations caused by umbilical cord compression.

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

NCC C-EFM uses NICHD terminology to describe key FHR characteristics: baseline, variability, accelerations, and decelerations. In this strip, the following findings are present:

Baseline:The baseline appears approximately 135–145 bpm, which is within the normal 110–160 bpm range described in NCC and AWHONN materials.

Variability:Beat-to-beat fluctuation is within 6–25 bpm, which meets the definition of moderate variability. NCC and NICHD define moderate variability as amplitude range of 6–25 bpm; this is associated with adequate fetal oxygenation and a normal fetal acid–base status.

Accelerations:The tracing shows distinct increases in FHR above the baseline by at least 15 bpm lasting 15 seconds or more but less than 2 minutes. NCC and NICHD define an acceleration in a term fetus precisely as “a visually apparent abrupt increase in FHR, with peak ≥15 bpm above baseline, lasting ≥15 seconds and <2 minutes.” The pattern shown fits this definition clearly.

Category determination:A tracing with normal baseline, moderate variability, and accelerations without decelerations is classified as Category I, not Category II. Category II is reserved for tracings that are not clearly Category I or III, such as minimal or marked variability, recurrent variables, or prolonged decelerations.

Marked variability consideration:Marked variability is defined as amplitude >25 bpm. While the tracing is somewhat jagged, the fluctuation does not sustain >25 bpm amplitude over a 10-minute segment and instead remains in the moderate range, so it does not meet criteria for marked variability.

Given these observations, the most accurate description of the tracing from the options provided is that it demonstrates accelerations.

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

NCC aligns with AWHONN’s “Practice Guidelines for Fetal Heart Monitoring”, which specify the appropriate frequency of intermittent auscultation (IA) based on labor phase and risk level. For low-risk patients in active labor, IA must occur:

Every 15–30 minutes during active labor

Every 5 minutes during second stage with pushing

AWHONN and Menihan emphasize that intermittent auscultation must follow standardized time intervals to ensure adequate fetal surveillance. These intervals reflect the physiologic understanding that fetal compromise may evolve over relatively short time periods, and active labor (4–7 cm dilation) represents a time of increasing stress on fetal oxygenation.

Simpson & Creehan explain that IA frequency should increase as labor intensifies, and that the 15–30-minute interval is the nationally recognized standard for low-risk active labor. NCC’s exam content domain “Fetal Assessment Methods” reinforces knowing these surveillance intervals for safe low-intervention care.

Thus, for a 4–5 cm dilated, low-risk, spontaneous labor, the correct IA interval is every 15–30 minutes.

References (No URLs)

NCC C-EFM Candidate Guide 2025 – Fetal Assessment Methods

AWHONN Practice Guidelines for Fetal Heart Monitoring, 2022–2024

Menihan: Electronic Fetal Monitoring

Simpson & Creehan: Perinatal Nursing

Miller: Fetal Monitoring Pocket Guide

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 (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–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 (NCC-Recommended Sources Only)

The fetal heart rate (FHR) tracing shown demonstrates a baseline approximately 135–145 bpm with fluctuations of 6–25 bpm, a hallmark of moderate variability. Moderate variability is defined in all NCC-endorsed resources as the normal amplitude range of 6–25 bpm around the fetal baseline.

According to the AWHONN Fetal Heart Monitoring Principles & Practices (2022–2024), moderate variability is considered the single most reliable indicator of adequate fetal oxygenation and intact neurologic pathways, specifically reflecting well-functioning sympathetic and parasympathetic interplay.

The NICHD/NCC standardized definitions included in the NCC C-EFM Candidate Guide state:

Minimal variability: amplitude range ≤ 5 bpm

Moderate variability: amplitude range 6–25 bpm

Marked variability: amplitude > 25 bpm

Sinusoidal pattern: smooth, undulating waveform, 3–5 cycles per minute, equal amplitude, absent beat-to-beat variability

The tracing provided does not show the repetitive, smooth, wave-like pattern of a sinusoidal rhythm; nor does it show flattening associated with minimal variability. Instead, it includes continuous beat-to-beat fluctuation within the moderate range, without periods of absent or minimal variability.

Menihan’s Electronic Fetal Monitoring (5th ed.) and Simpson & Creehan’s Perinatal Nursing (5th ed.) both emphasize that moderate variability is:

A reassuring feature

Indicative of adequate fetal CNS oxygenation

Expected in a reactive, well-oxygenated fetus

A key criterion for Category I classification

Additionally, Miller’s EFM Pocket Guide reiterates that variability between 6–25 bpm is considered the normal (moderate) fetal autonomic response and is not a sinusoidal pattern, which has a fixed amplitude and frequency.

Therefore, based on NCC-standard definitions and the observed amplitude, the correct interpretation is moderate variability.

References (No URLs):

AWHONN Fetal Heart Monitoring Principles & Practices; NCC C-EFM Candidate Guide 2025; Simpson & Creehan Perinatal Nursing; Menihan Electronic Fetal Monitoring; Miller’s Pocket Guide to Fetal Monitoring; Creasy & Resnik Maternal-Fetal Medicine.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The strip shows abrupt, deep variable decelerations, which are highly suspicious for cord compression.

Following rupture of membranes, the FIRST step recommended by NCC/AWHONN is:

Immediate vaginal examination to rule out cord prolapse.

Cord prolapse requires emergent action, and examination must occur before repositioning or fluids.

Why the other answers are incorrect:

C. Left lateral positioning is appropriate after ruling out cord prolapse.

A. IV fluids do not address the potentially life-threatening cause.

Correct first action is: vaginal examination.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Artifact on fetal monitoring:

Appears erratic, disorganized, and without physiologic pattern

Shows random amplitude changes

Often correlates with maternal movement, monitor displacement, or poor signal

Lacks cyclical, repetitive characteristics seen in true dysrhythmias

Fetal dysrhythmias, by contrast:

Have repetitive, patterned, predictable rhythm disturbances

May show uniform premature beats, bigeminy, or sudden rate shifts

Therefore, varied and disorganized = artifact.

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 (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 <</b>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.