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 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 (No URLs)

For fetuses before 32–34 weeks, the National Certification Corporation (NCC) follows the physiologic standards established by AWHONN, Simpson & Creehan, Menihan, and Creasy & Resnik, which emphasize that preterm fetuses have less mature autonomic nervous system development, resulting in smaller and shorter accelerations.

According to the NCC C-EFM Exam Content Outline (Pattern Recognition & Intervention) and the AWHONN Fetal Heart Monitoring Principles (2022–2024):

Preterm fetuses (<32 weeks) normally demonstrate 10 bpm × 10 sec accelerations.

By approximately 32–34 weeks, accelerations may begin transitioning toward 15×15, but the accepted standard for documentation at 34 weeks remains 10×10, unless clearly meeting 15×15 criteria.

NCC emphasizes using gestational-age–appropriate criteria for documenting accelerations, because autonomic reactivity increases gradually and is not fully comparable to term until after 32–34 weeks.

Menihan’s Electronic Fetal Monitoring also states that preterm fetuses “should be evaluated with the 10×10 rule until it is clear that the fetus is demonstrating mature 15×15 acceleratory capacity.”

Simpson & Creehan reinforce this point, noting that accelerations in late preterm gestations “may not consistently reach 15 bpm for 15 seconds, and thus 10×10 remains the appropriate designation.”

Since the patient is 34 weeks, the fetus is late-preterm and may not reliably meet the full 15×15 criteria; therefore, the correct documentation standard remains 10×10.

Thus, accelerations should be charted as:

“Present 10×10.”

References

NCC C-EFM Candidate Guide 2025 – Content Domain: Pattern Recognition and Intervention

AWHONN Fetal Heart Monitoring Principles & Practices, 2022–2024

Menihan: Electronic Fetal Monitoring: Concepts and Applications

Simpson & Creehan: Perinatal Nursing

Miller: Fetal Monitoring Pocket Guide

Creasy & Resnik: Maternal–Fetal Medicine

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 (NCC-Referenced Sources)

According to AWHONN, Simpson, and NCC C-EFM physiologic competencies, uterine rupture commonly presents with:

Sudden prolonged deceleration

Recurrent variables

Fetal bradycardia

Possible loss of station, vaginal bleeding, maternal pain

AWHONN specifically lists:

“Prolonged deceleration is the most common initial fetal sign of uterine rupture.”

Absent variability can occur later, but it is not the most common initial pattern.

“Loss of uterine pressure” refers to loss of toco signal, not a fetal heart rate characteristic.

Therefore, NCC-validated interpretation: prolonged and variable decelerations.

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

A biophysical profile (BPP) assesses 5 components:

FHR reactivity

Fetal breathing movements

Fetal tone

Fetal movement

Amniotic fluid volume

According to NCC/AWHONN, fetal breathing movements are controlled by the fetal central nervous system, specifically brainstem integrity.

Thus, fetal breathing movements signify normal neurologic function, particularly intact CNS and oxygenation.

Why the others are incorrect:

Pulmonary vasoconstriction is not assessed by BPP.

Surfactant levels do not correlate directly with fetal breathing movement scores.

Correct answer: A. Neurologic function.

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

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.

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

AWHONN and NICHD definitions state that fetal accelerations are a strong indicator of adequate fetal oxygenation and neurologic integrity. Accelerations reflect intact sympathetic and parasympathetic balance and adequate oxygen reserve.

Simpson & Creehan emphasize accelerations as “the most reliable sign of fetal well-being,” because they require intact autonomic function, sufficient pH, and adequate oxygenation. Menihan also identifies accelerations as the most reassuring feature on a fetal heart tracing.

Fetal movement is helpful but not directly reflective of oxygenation, as movements can decline for non-hypoxic reasons (sleep cycles, maternal sedation). Regular sleep–wake cycles are normal developmental neurologic patterns and not oxygenation markers.

Creasy & Resnik reinforce that “presence of accelerations reliably indicates absence of metabolic acidemia.”

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

The tracing demonstrates a very rapid, highly regular baseline fetal heart rate with minimal beat-to-beat variability—characteristic of fetal supraventricular tachycardia (SVT). NCC-recommended references, including AWHONN’s Fetal Heart Monitoring Principles & Practices, Menihan’s Electronic Fetal Monitoring: Concepts and Applications, Simpson & Creehan’s Perinatal Nursing, and Creasy & Resnik’s Maternal-Fetal Medicine all describe fetal SVT as a sustained tachyarrhythmia usually greater than 200 bpm, narrow-complex, and extremely regular in appearance.

AWHONN teaches that SVT appears as a “tight, rapid, uniform baseline with minimal variability.” Menihan states that “SVT may present on EFM as a nearly straight line due to the rapid, consistent rate with micro-oscillations.” This differs significantly from artifact, which appears disorganized, erratic, and inconsistent in amplitude. Additionally, “half-counting” is a Doppler misinterpretation that records half of an extremely fast fetal rate, usually resulting in a falsely lower heart rate—not the very rapid tracing shown here.

Creasy & Resnik emphasize that SVT is the most common pathological fetal arrhythmia and can lead to fetal compromise if prolonged, making accurate recognition essential. Miller’s Pocket Guide to Fetal Monitoring also identifies SVT as a pattern with a “smooth, fast rhythm lacking normal variability.”

All authoritative NCC-recommended references support that this EFM pattern is consistent with fetal SVT, not artifact or half-counting.

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:

Sustained fetal supraventricular tachycardia (SVT) often produces heart rates > 200–240 bpm, causing:

Poor ventricular filling

Decreased stroke volume

Reduced cardiac output

Congestive heart failure

Progressive fluid accumulation

NCC and AWHONN emphasize that untreated SVT leads to hydrops fetalis, characterized by:

Ascites

Pleural effusion

Pericardial effusion

Skin edema

Why the other answers are incorrect:

A. Fetal anemia — Causes tachycardia but is not caused by SVT.

C. Neonatal pacemaker — Pacemakers treat heart block, not SVT.

Correct answer: B. Hydrops fetalis

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

According to NCC, AWHONN, and evidence-based documentation standards, clinicians must document:

Baseline

Variability

Accelerations

Decelerations (type, depth, duration, timing)

Uterine activity

This fulfills the NICHD 3-tier system and legal documentation expectations.

Why the incorrect answers are wrong:

B. "Normal/abnormal" → vague, not an acceptable documentation standard.

C. Category alone → insufficient; categories must be supported by the components.

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 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–Based NCC C-EFM References:

NCC and NICHD differentiate:

Periodic decelerations – those occurring with contractions

Episodic decelerations – those occurring independent of contractions

Deceleration types:

Early – periodic (mirror contractions)

Late – periodic (after peak of contraction)

Variable – may be periodic or episodic, and are the only type strongly associated with episodic patterns**

Therefore, the only deceleration type that is characteristically episodic is a variable deceleration.

Correct answer: C. Variable deceleration

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 NCC-Aligned Sources:

The single best indicator of fetal oxygenation and neurologic integrity is:

Moderate baseline variability

Variability reflects:

Normal autonomic regulation

Adequate fetal oxygenation

Intact neurologic pathways

Absence of decelerations is helpful but not as predictive.

Baseline FHR (e.g., 140–150) is normal, but baseline alone does not confirm well-being.

Correct answer: C. Presence of variability

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Vagal stimulation is part of the parasympathetic nervous system, which causes:

Slowing of the fetal heart rate (FHR)

Rapid but temporary changes in HR

Seen with head compression, scalp stimulation, or fetal movement

NICHD/NCC physiology explains:

Vagus nerve activation → acetylcholine release → slowed SA node firing → decrease in FHR

This mechanism is responsible for early decelerations during labor due to head compression.

Why the incorrect answers are wrong:

B. Increased cardiac contractility → sympathetic effect, not vagal.

C. Increased fetal blood pressure → also a sympathetic effect.

Correct answer: A. Decreased fetal heart rate

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 NCC-Aligned Sources:

NICHD/NCC criteria:

Category I must have ALL of the following:

Baseline 110–160 bpm

Moderate variability

No late or variable decelerations

Early decelerations may be present or absent

Accelerations may be present or absent

Because this tracing has one variable deceleration, it fails Category I criterion (“no late or variable decelerations”).

Category III requires:

Absent variability with recurrent late decels, recurrent variables, or bradycardia, or

Sinusoidal pattern

Those findings are not present.

Therefore, any tracing that:

Has moderate variability and accelerations,

But includes a variable deceleration, and

Does not meet Category III criteria

…falls into the Category II (indeterminate) group.

Correct classification: B. Category II.

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

On the tracing:

FHR consistently ranges 170–185 bpm.

Variability remains present, confirming adequate signal.

This pattern persists for the required minimum 10-minute baseline window.

NICHD/NCC define fetal tachycardia as:

Baseline > 160 bpm for at least 10 minutes

Because the FHR is well above 160 for the whole reviewable period, the baseline is tachycardic.

Why the other answers are incorrect:

A. 155 bpm — Too low; FHR visually averages well above this.

B. Indeterminate — Not applicable; variability is clear and the tracing meets the ≥10-minute rule.

Correct answer: C. Tachycardia

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 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 Exact Extract Without Any URLs or Links:

The NCC C-EFM Professional Issues domain identifies informed consent as a fundamental ethical requirement in fetal monitoring. AWHONN’s perinatal nursing standards state that the clinician must provide clear explanation of risks, benefits, alternatives, and the purpose of EFM, ensuring the patient makes a voluntary and informed decision.

Simpson, Creasy & Resnik, and ACOG-referenced materials used by NCC emphasize that informed consent is the process, while autonomy is the principle that supports it. The act of explaining EFM and its implications is therefore informed consent, not autonomy itself.

In the NCC competencies, clinicians must:

Provide accurate information

Support shared decision-making

Verify maternal understandingThis exactly matches the process of informed consent, not merely respecting autonomy or acting as a fiduciary.

Comprehensive and Detailed Explanation From Exact Extract NCC-Recommended Sources

NCC-recommended physiology references (AWHONN, Simpson & Creehan, Menihan, Creasy & Resnik) consistently state that the primary mechanism by which tachysystole affects fetal oxygenation is reduced uteroplacental perfusion, specifically through impaired intervillous space reperfusion.

During a normal contraction cycle, the fetus receives oxygen between contractions, when the uterus relaxes and maternal blood re-enters the intervillous space. AWHONN’s Fetal Heart Monitoring Principles & Practices explains that tachysystole—defined as more than five contractions in 10 minutes averaged over 30 minutes—shortens or eliminates the relaxation phase, preventing adequate placental reoxygenation.

Simpson & Creehan highlight that “tachysystole decreases uteroplacental blood flow and interferes with replenishment of oxygenated maternal blood in the intervillous space.” Menihan emphasizes that fetal hypoxemia in tachysystole results from interrupted perfusion, not from altered oxygen transport or maternal hemodynamic changes. Creasy & Resnik confirm that uterine overactivity reduces intervillous perfusion during contractions and impairs fetal oxygen exchange.

Thus, the physiologic problem is failure of the intervillous space to reperfuse, which compromises fetal oxygenation.

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

NCC and AWHONN standards state that the fetal heart tones are most clearly heard when the Doppler probe is placed over the fetal back, because:

The fetal heart transmits sound most directly through the fetal spine.

Amniotic fluid and fetal position allow the strongest conduction at the back.

During Leopold maneuvers, identification of the back guides optimal placement.

Placing the Doppler over the abdomen or chest does not provide the strongest or most reliable fetal signal.

Therefore, the correct placement is over the fetal back.

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 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 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 NCC C-EFM–Referenced Sources)

The NCC C-EFM exam outline, along with AWHONN and Miller’s Pocket Guide, define baseline fetal heart rate as the mean FHR rounded to increments of 5 bpm, measured over a 10-minute window, excluding:

• accelerations

• decelerations

• periods of marked variability

• any segments differing by >25 bpm

This aligns with ACOG, AWHONN, and Simpson’s interpretation standards.

Option A is incorrect: the baseline is not documented as a 15-bpm range; it is documented as a single value (e.g., 140 bpm).

Option C is incorrect: the correct NCC/ACOG standardized normal baseline is 110–160 bpm, not 170.

Exact Extract Concepts Referenced:

– “Baseline is determined over a 10-minute period excluding periodic or episodic changes.” (AWHONN FHR Principles)

– “Baseline is the mean FHR rounded to 5-bpm increments.” (Miller’s Pocket Guide)

– “Normal baseline is 110–160 bpm.” (Simpson & Menihan; Creasy & Resnik)

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:

Post-dates surveillance focuses on:

Amniotic fluid volume (AFI or deepest vertical pocket)

This is the most sensitive parameter of placental function

Oligohydramnios is strongly associated with post-maturity and perinatal morbidity

NCC and AWHONN emphasize amniotic fluid as the primary parameter for fetal well-being in post-term surveillance.

Why the incorrect answers are wrong:

B. Fetal weight → inaccurate and not used for surveillance decisions.

C. Placental calcification → poor predictor of fetal outcome and not used for management.

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.