NCC EFM Certified - Electronic Fetal Monitoring Exam Practice Test

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 Exact Extract–Based NCC C-EFM References:

NCC and AWHONN physiology teachings:

Variable decelerations caused by cord compression lead to:

Transient interruption of umbilical venous flow

Impaired fetal gas exchange

Acute rise in CO₂

Respiratory acidosis (early phase of hypoxemia)

This is well documented:

Early decelerations → head compression → NOT associated with acidemia.

Late decelerations → uteroplacental insufficiency → metabolic acidosis, not respiratory.

Thus:

Variable decelerations → respiratory acidosis

Late decelerations → metabolic acidosis

Correct answer: C. Variable

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 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:

Whenever a fetal heart rate is unexpectedly low (such as 90 bpm), the FIRST step per NCC and AWHONN is to confirm that the signal is fetal, not maternal.

Even internal spiral electrodes can capture maternal heart rate, especially after:

Rupture of membranes

Maternal hypotension

Maternal dehydration

Maternal tachycardia or bradycardia

Thus, the first, most immediate action is:

→ Palpate the maternal radial pulse to determine whether the tracing is maternal or fetal.

If rates match → the monitor is falsely detecting the maternal pulse.

If rates differ → confirm true fetal bradycardia and begin intrauterine resuscitation.

Why the other options are incorrect:

A. Intrauterine resuscitation — should NOT begin before confirming the tracing is fetal.

C. Bedside ultrasound — appropriate after confirming that the tracing is not maternal, not before.

Correct answer: B. Palpation of the maternal radial pulse.

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 NCC-Aligned Sources:

Normal umbilical arterial values per NCC/AWHONN/Menihan:

pH: 7.20–7.30

PaCO₂: 45–55 mmHg

HCO₃: 20–24 mEq/L

Base deficit: 0 to –5 (normal to mild respiratory changes)

This sample shows:

pH 7.25 → normal

Base deficit –4 → no metabolic acidosis

HCO₃ normal

Slightly elevated PaCO₂, consistent with mild respiratory influence but still normal

PaO₂ 20 mmHg is normal for cord arterial blood

This profile is not acidotic (acidosis requires pH <7.10 and base deficit ≥12).

It also does not indicate hypoxia, which would present with metabolic acidosis.

Therefore: Normal.

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–Based NCC C-EFM References:

Maternal hyperthermia—most commonly from infection—causes a rise in fetal temperature, which increases fetal metabolic rate. The fetus responds by increasing heart rate to meet the increased oxygen demand.

Effects include:

Increased fetal oxygen consumption

Enhanced fetal cardiac output

Resultant tachycardia, often 160–180 bpm

This mechanism is repeatedly outlined in NCC’s physiology domain, AWHONN, Menihan, Simpson, and Creasy & Resnik.

Option A is incorrect because maternal fever does not reduce perfusion.

Option C is incorrect because catecholamines are often elevated, not inhibited.

Thus, the mechanism is increased fetal metabolism.

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 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:

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 (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 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 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

NCC-recommended fetal assessment texts emphasize that external Doppler ultrasound may undercount very rapid fetal arrhythmias such as fetal supraventricular tachycardia (SVT). Because Doppler detects mechanical motion rather than electrical activity, the device may record only every other cardiac contraction, a phenomenon known as “half-counting.”

Menihan’s Electronic Fetal Monitoring explains that with SVT—often exceeding 200 to 260 bpm—the monitor “may display a fetal heart rate at approximately half the true atrial rate.” AWHONN teaching materials affirm that rapid, regular tachyarrhythmias may appear deceptively slower on the external monitor due to Doppler under-sampling. Simpson & Creehan note that half-counting is a recognized technical limitation and may cause clinicians to miss true tachyarrhythmias if internal monitoring is not applied.

In contrast, artifact displays irregular, inconsistent, and non-physiologic deflections. Matching the maternal pulse suggests maternal heart rate misinterpretation, not SVT.

Miller’s Pocket Guide also highlights that half-counting is “commonly seen in fetal SVT when using external Doppler due to failure to detect each rapid contraction.”

Therefore, fetal SVT most commonly appears as half the actual rate on an external fetal monitor.

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’s Fetal Assessment Text, Simpson & Miller, and Menihan, vibroacoustic stimulation is utilized during NSTs to elicit fetal accelerations, thereby minimizing testing time.

NCC-referenced sources describe VAS as:

• A method that awakens the fetus,

• Stimulates the fetal auditory system,

• Produces reactive accelerations in a neurologically intact fetus,

• Dramatically shortens NST duration, especially when the fetus is in a sleep cycle.

VAS does NOT measure amniotic fluid, nor does it have any effect on uterine activity (therefore cannot treat tachysystole).

The only correct purpose supported by NCC-cited literature is that VAS shortens the duration of the NST, making Option C correct.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Both fetal tracings (A and B) show:

Baselines around 140–150 bpm

Moderate variability

Intermittent accelerations

No recurrent decelerations

Normal contraction pattern

Overall Category I patterns for both twins

NCC, NICHD, and AWHONN emphasize that moderate variability with a normal baseline is the strongest reassurance of fetal well-being, even in multifetal gestations.

There is no evidence of:

Tachysystole

Recurrent variables

Recurrent lates

Prolonged decelerations

Category III patterns

Therefore, the appropriate action is ongoing observation.

Why the incorrect answers are wrong:

A. Cesarean birth — Not indicated with Category I FHR patterns.

C. Terbutaline — Reserved for tachysystole or prolonged deceleration patterns, not present here.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

NCC defines amnioinfusion as indicated for:

Recurrent variable decelerations caused by cord compression

Oligohydramnios reducing buffer around the cord

Expected effect:

Reduction or elimination of variable decelerations

Why the other answers are incorrect:

A. Variability does not improve with amnioinfusion.

B. Baseline FHR does not increase as a result of amnioinfusion.

Correct answer: C. Resolution of variable decelerations.

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–Based NCC C-EFM References:

Fetal baroreceptors, located primarily in the carotid sinus and aortic arch, respond to increases in fetal arterial pressure. When activated, they stimulate the vagus nerve, causing:

Reflex parasympathetic activation

Decreased FHR (vagal slowing)

This is a well-established physiologic mechanism referenced throughout NCC’s physiology domain. NCC emphasizes that variable decelerations, especially short deep drops, can occur when transient increases in fetal blood pressure from cord compression activate these baroreceptors.

Option B, decreased PO₂, relates to chemoreceptor-mediated responses—not baroreceptors.

Option C, reflex tachycardia, is mediated by sympathetic activation and occurs when BP falls, not rises.

Thus, the correct physiologic response is A. Decreased heart rate.

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 Exact Extract (No URLs or Links):

According to the NCC C-EFM exam outline and AWHONN Fetal Heart Monitoring Principles (2022), the first step when evaluating a concerning fetal heart rate pattern is to verify uterine activity, because the fetal response is often directly associated with contraction frequency, strength, or tachysystole. AWHONN states that “the clinician must confirm maternal–fetal physiology and uterine activity by palpation when interpreting any FHR pattern, as tocodynamometry may under- or overestimate uterine pressure.” Menihan’s Electronic Fetal Monitoring further emphasizes: “Always validate the contraction pattern via maternal abdominal palpation before proceeding with additional interventions.”

The tracing shows a late-appearing deceleration pattern with uncertain contraction correlation because the external toco waveform is inadequate (flat or poorly recorded). Before determining whether the decelerations are early, late, or variable, the clinician must confirm whether contractions are present, absent, or excessive. This step is listed as a core competency under Pattern Recognition & Intervention in the NCC Candidate Guide.

Therefore, palpating for contractions is the required first intervention.

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

The fetal heart rate is calculated from the interval between consecutive R waves in the fetal ECG. Shorter R-R intervals indicate more beats per unit of time, therefore resulting in a higher heart rate. AWHONN and Menihan both note that fetal ECG monitoring measures instantaneous rate based on R-R spacing, and “shorter intervals correspond to fetal tachycardia.”

Simpson & Creehan reinforce that fetal heart rate variability and baseline are derived from these R-R intervals, with shorter intervals consistently producing faster rates. Miller’s Pocket Guide describes the relationship simply: “Short R-R = faster rate; long R-R = slower rate.”

Comprehensive and Detailed Explanation From Exact Extract (NCC-Referenced Sources)

AWHONN and Menihan clearly state that classification of decelerations is determined by their timing relative to uterine contractions:

Early decelerations: “mirror the contraction; onset, nadir, and recovery occur simultaneously with the contraction.”

Late decelerations: “begin after the contraction begins and return to baseline after the contraction ends.”

Depth is not a differentiating feature, as both early and late decelerations may vary in depth. The onset-to-nadir interval is used to differentiate variable vs. early/late, not early vs. late.

Thus, timing relative to contractions is the correct NCC-supported answer.

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

Intrauterine pressure catheters (IUPCs) are an internal uterine activity monitoring device used when external tocodynamometry does not provide adequate assessment of contraction strength or frequency. According to NCC, AWHONN, Miller, and Menihan, the primary indication for placing an IUPC is to obtain accurate, quantitative measurement of uterine activity.

Purpose of IUPC (per NCC and AWHONN):

Measures exact intrauterine pressure in mmHg

Calculates Montevideo units (MVUs) to evaluate adequacy of labor

Clearly differentiates:

Frequency

Duration

Strength (intensity)

Resting tone

NCC explicitly lists the primary purpose as:

“Accurate assessment of uterine contraction pattern and intensity.”

Why the other options are incorrect:

A. Define the quality of the fetal baseline – Incorrect

Fetal heart rate (FHR) baseline quality is determined by fetal ECG or FSE, not IUPC.

IUPCs monitor the uterus, not the fetal cardiac signal.

C. Rule out artifact – Incorrect

While an IUPC can reduce artifact from the toco, this is not its primary purpose.

Artifact is more commonly an issue with external FHR monitoring, corrected by repositioning or placing a fetal scalp electrode—not by using an IUPC.

Correct Answer:

B. Determine the contraction pattern

This aligns directly with NCC’s Electronic Monitoring Equipment domain: IUPCs provide the most accurate and reliable measurement of uterine activity when external monitoring is inadequate.

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 NCC-Aligned Emergency Fetal Response Principles:

Following an eclamptic seizure:

Maternal hypoxia, apnea, and intense sympathetic discharge occur

Uteroplacental perfusion drops

Fetus experiences acute hypoxemia

The expected fetal heart rate response is a prolonged bradycardia

This is well-described in NCC and AWHONN emergency physiology:

“Post-seizure fetal bradycardia is common and often resolves within 5–10 minutes as maternal oxygenation stabilizes.”

Why other answers are incorrect:

B. Sinusoidal pattern — Rare and usually indicates fetal anemia, not post-seizure status.

C. Variable decelerations — Associated with cord compression, not seizures.

Correct answer: A. Bradycardia

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Renal agenesis → severe oligohydramnios (due to absent fetal urine production).

Oligohydramnios causes:

Cord compression

Recurrent variable decelerations

Possible prolonged decels from cord entrapment

This is one of the hallmark FHR complications in renal agenesis.

Why the other options are incorrect:

A. Heart block — associated with maternal autoimmune antibodies, not renal anomalies.

B. Late decelerations — associated with uteroplacental insufficiency, not fluid deficiency.

Correct answer: C. Variable decelerations.

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 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 NCC-Aligned Sources:

This tracing shows:

Baseline ~145 bpm

Minimal variability

No accelerations or decelerations

Very little fluctuation → resembles a flat/minimal variability Category II tracing

The key physiologic mechanism behind minimal variability in the presence of a normal baseline and normal contraction pattern is most often:

Increased fetal sympathetic tone, driven by catecholamine release (epinephrine and norepinephrine).

NCC and AWHONN explain:

Catecholamine release (due to fetal stress, early hypoxemia, or maternal stress) results in:

Reduced beat-to-beat fluctuation

Minimal baseline variability

This is considered an early compensatory mechanism, not yet a decompensated hypoxic state.

Why the other answers are incorrect:

A. Myocardial hypoxic depression

Causes absent variability, NOT minimal variability.

Represents advanced or severe hypoxia. The FHR here is not absent variability.

C. Vagal stimulation in response to hypoxemia

Produces decelerations, especially late or prolonged.

This strip shows no decelerations, ruling this out.

Therefore the most accurate physiologic explanation is B. Release of catecholamines.

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–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:

The tracing clearly shows recurrent deep variable decelerations, characterized by:

Abrupt onset (<30 sec)

Sharp V-shape

Rapid descent and ascent

Depth exceeding 60–70 bpm drops

Occurring with most contractions

This pattern is highly consistent with cord compression, which is the physiologic basis of variable decelerations. According to NCC, NICHD, AWHONN, Miller, and Menihan, recurrent (≥50% of contractions) deep variables with slow return to baseline indicate fetal compromise and require targeted intervention.

The patient has already been repositioned, so first-line management has failed. NCC emphasizes that the next recommended intervention for recurrent variable decelerations, particularly when maternal repositioning is ineffective, is amnioinfusion. This intervention relieves cord compression by restoring fluid around the umbilical cord.

Why the other choices are incorrect:

A. Apply a spiral electrode – NOT appropriate

Spiral electrodes improve signal quality but do not treat cord compression.

The tracing is already clearly interpretable, and the issue is physiologic, not technical.

B. Decrease the oxytocin – Not the best next step

Decreasing oxytocin is appropriate when tachysystole is contributing to fetal intolerance.

This strip shows normal contraction frequency (about every 2–3 minutes) and no tachysystole.

Thus, reducing oxytocin alone will not relieve cord compression.

C. Perform an amnioinfusion – CORRECT

NCC-approved references repeatedly state:

For recurrent variable decelerations that persist after maternal repositioning, amnioinfusion is recommended to reduce the frequency and depth of decelerations.

It can improve fetal oxygenation, decrease cord compression, and reduce the need for operative delivery.

It is the intervention most directly targeted to the pathophysiology of this pattern.

Therefore, C. Perform an amnioinfusion is the correct next management step.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Second-stage bradycardia with moderate variability most commonly occurs from:

Vagal stimulation caused by head compression, particularly during descent and pushing.

Moderate variability indicates:

Neurologically intact fetus

Sufficient oxygen reserve

Temporary nature of bradycardia

This aligns with physiologic vagal slowing rather than hypoxic mechanisms.

Why the incorrect answers are wrong:

A. Cord compression → typically produces variable decelerations, not sustained bradycardia with preserved variability.

C. Vasospasm → associated with late decelerations and decreased variability (uteroplacental insufficiency).

Correct answer: B. Vagal stimulation