EFM Certified - Electronic Fetal Monitoring Questions and Answers

Comprehensive and Detailed Explanation From NCC-Aligned Physiologic Sources:

Oxygen transfer occurs at the maternal–fetal interface within the intervillous space, where:

Maternal blood from the spiral arteries bathes the chorionic villi

Diffusion occurs between maternal blood and fetal capillary beds

Oxygen then travels through fetal circulation via the umbilical vein

Thus:

Intervillous space = site of gas exchange

Spiral arteries = deliver maternal blood to that space

Umbilical vein = fetal vessel carrying oxygenated blood after exchange has occurred

Correct answer: A. Intervillous space

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

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

Key features in this tracing:

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

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

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

Why the incorrect answers are ruled out:

A. Atrial flutter – NOT supported

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

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

FHR in atrial flutter appears more organized, not chaotic.

B. Complete heart block – NOT supported

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

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

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

C. Fetal dysrhythmia – CORRECT

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

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

The tracing shown matches these characteristics precisely.

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

Comprehensive and Detailed Explanation From Exact Extract 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 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 Exact Extract NCC-Recommended Sources

Variability is created by beat-to-beat differences in fetal cardiac intervals due to autonomic nervous system modulation. AWHONN specifies that absent variability appears as “a near-straight line with minimal or no discernible oscillations,” which occurs when all beat intervals are identical.

Menihan notes that Doppler displays variability based on mechanical motion and will show flat, unchanging intervals when fetal autonomic modulation is suppressed, reflecting absent variability.

Bradycardia refers to a baseline <110 bpm and does not describe the uniformity of intervals. A normal baseline may still show variability; it cannot have identical beat-to-beat intervals, as this violates the definition of variability in NICHD terminology.

Simpson & Creehan state that absent variability is a significant marker of impaired fetal oxygenation or CNS depression.

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

The tracing shows tachysystole with emerging late decelerations and minimal variability:

5 contractions in 10 minutes

Deceleration nadirs occur after the peak of the contraction (late pattern)

Variability begins to trend toward minimal

The tracing has deteriorated while on oxytocin 8 mU/min, a common threshold for overstimulation

NCC and AWHONN emphasize that when tachysystole occurs with any fetal intolerance, the first action is to reduce or stop oxytocin.

Key NCC principles:

Late decelerations + tachysystole = uteroplacental insufficiency caused by excessive uterine activity

Interventions:

Stop or reduce oxytocin

Maternal repositioning

IV fluid bolus

Possible oxygen if other measures fail

Why the other options are incorrect:

A. Continue to observe — not acceptable with late decels + tachysystole.

C. Place a spiral electrode — this corrects signal quality, not uterine overstimulation or fetal oxygenation.

Thus, the best initial response is B. Decrease the oxytocin.

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 (No URLs):

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

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

• Bradycardia NOT accompanied by absent variability

• Tachycardia

• Minimal variability

• Marked variability

• Absence of accelerations after stimulation

• Recurrent variable decelerations with minimal or moderate variability

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

In this tracing, the fetus demonstrates:

– A prolonged deceleration with subsequent recovery,

– Presence of baseline variability,

– Return toward baseline but not immediately normal.

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

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

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

The tracing displays baseline fetal bradycardia, with a rate near 100 bpm, minimal variability, and preserved periodic response. According to AWHONN’s Fetal Heart Monitoring Principles & Practices and Menihan’s Electronic Fetal Monitoring, maternal conditions that reduce oxygen-carrying capacity—including maternal anemia—can lead to lower fetal oxygen delivery, prompting a fetal compensatory bradycardic baseline.

Creasy & Resnik’s Maternal-Fetal Medicine notes that sickle cell anemia decreases maternal hemoglobin function even when maternal vital signs appear stable, reducing uteroplacental oxygen transport. Fetuses of mothers with sickling disorders may demonstrate lower resting fetal heart rates due to chronic mild hypoxemia.

Conversely, Eisenmenger’s syndrome is associated with severe maternal cyanosis and high fetal mortality, often producing late decelerations and growth restriction rather than mild bradycardia. Systemic lupus erythematosus (SLE) is commonly associated with heart block (especially with anti-Ro/SSA antibodies), which is not displayed here, as true heart block presents with a fixed atrial–ventricular dissociation and FHR < 60 bpm.

Thus, based on fetal physiology and maternal disease correlations taught in NCC-recommended sources, the tracing is most consistent with maternal sickle cell anemia.

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 (NCC-Referenced Sources)

Mono-mono twins share a single amniotic cavity, which significantly increases the risk of cord entanglement, a concept highlighted in AWHONN FHM, Creasy & Resnik Maternal-Fetal Medicine, and Miller’s EFM Pocket Guide.

These texts emphasize:

“Cord entanglement is nearly universal in monoamniotic twins.”

“Variable decelerations are common due to recurrent cord compression.”

Baseline tachycardia or minimal variability are not expected baseline characteristics, but may appear only in pathologic circumstances.

Thus, variable decelerations are the expected and anticipated FHR pattern in mono-mono twins.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

NCC and AWHONN auscultation standards emphasize the need to document FHR findings relative to uterine contractions, including:

The FHR between contractions (baseline)

FHR during contractions

Presence/absence of decelerations

Recovery after a contraction

Uterine activity determines whether findings are:

Baseline

Accelerations

Early/late/variable decelerations

Why the other options are incorrect:

A. Fetal position — relevant for Doppler placement, not auscultation documentation.

B. Stage of labor — affects monitoring frequency but does not change how findings are documented.

Correct answer: C. Uterine activity.

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 (No URLs):

NCC references (AWHONN, Menihan, Simpson, Creasy & Resnik) consistently state that fetal accelerations are a reassuring sign of intact neurologic function. Accelerations represent the interaction of both the sympathetic and parasympathetic branches moderated through the central nervous system, reflecting effective autonomic regulation.

AWHONN specifically describes fetal accelerations as:

• A maturity marker of CNS function,

• Reflecting vigorous fetal movement,

• Demonstrating adequate oxygenation,

• Indicating a well-oxygenated brainstem and cortex.

Simpson & Miller emphasize that accelerations require both systems to be functioning and respond appropriately, which confirms CNS integration, not sympathetic or parasympathetic dominance alone.

Therefore, spontaneous accelerations indicate an integrated CNS response, making Option C the correct NCC-aligned answer.

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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:

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 Exact Extract–Based NCC C-EFM References:

The tracing shows a clear relationship between uterine activity and fetal heart rate changes:

The uterine activity strip demonstrates very frequent contractions with little resting time between them, exceeding five contractions in 10 minutes, averaged over a 30-minute window.

NCC and NICHD define tachysystole as “more than 5 contractions in 10 minutes, averaged over 30 minutes, regardless of whether the labor is spontaneous or stimulated.”

As uterine activity intensifies and becomes excessively frequent, the fetal heart rate strip begins to show:

Progressive decrease in baseline

Recurrent decelerations with gradual onset and recovery

Reduced variability in the latter portion of the strip

This pattern is consistent with uteroplacental insufficiency caused by excessive uterine activity (tachysystole). NCC and AWHONN emphasize that tachysystole can result in decreased uterine blood flow and fetal oxygenation, leading to late or prolonged decelerations and eventual bradycardia if not corrected.

Why the other options are less likely:

A. Placental abruptionTypically associated with maternal symptoms (pain, vaginal bleeding, firm/boardlike uterus) and often a sustained increase in resting tone or a hypertonic contraction, not simply very frequent contractions. These maternal findings are not described in the vignette.

B. Rapid fetal descentUsually causes variable or early decelerations related to head compression, but the tocodynamometer would not necessarily show this degree of contraction frequency. The lower strip here clearly highlights excessive contractions as the primary problem.

Thus, the tracing’s FHR abnormalities are best explained by tachysystole, making C. Tachysystole the most appropriate answer.

Comprehensive and Detailed Explanation From Exact Extract Sources:

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

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

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

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

By contrast:

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

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

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

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

This tracing shows:

Baseline approximately 135–140 bpm

Minimal variability

No accelerations

No recurrent decelerations

Category II for 20 minutes

According to NCC, AWHONN, and NICHD, minimal variability persisting ≥ 20 minutes without accelerations requires assessment of fetal acid-base status, and fetal scalp stimulation is an accepted method to evaluate fetal well-being when a Category II tracing persists.

Fetal scalp stimulation:

Should produce an acceleration ≥ 15 bpm lasting ≥ 15 seconds

A positive response indicates intact fetal nervous system and normal pH

If no acceleration occurs → further intrauterine resuscitation or expedited delivery may be required

Why other options are incorrect:

A. Delivery — Not indicated; this is Category II, not Category III.

C. IV bolus — IV hydration may improve variability, but assessment of fetal status comes first after 20 minutes of minimal variability.

Thus, the correct answer is B. Fetal scalp stimulation.

Comprehensive and Detailed Explanation From NCC-Aligned BPP Management Standards:

NCC, AWHONN, and maternal-fetal medicine guidelines state:

A BPP score of 4/10 at term is abnormal.

A low score indicates hypoxia-related CNS suppression.

Oligohydramnios is an additional high-risk finding, especially in hypertension.

At ≥ 37 weeks, a BPP score of ≤ 4/10 warrants immediate delivery.

Repeating the test is acceptable at preterm gestations (e.g., < 32–34 weeks), but not at 38 weeks.

Why the other answers are incorrect:

B. Discharge home — Contraindicated with abnormal BPP.

C. Repeat in 24 hours — Not recommended at term with a score of 4.

Correct answer: A. Admit for delivery

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:

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 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 without any URL or Links

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

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

Minimal or marked variability

Absence of accelerations after fetal stimulation

Recurrent variable decelerations with moderate variability

Prolonged decelerations lasting 2–10 minutes

Baseline tachycardia or bradycardia without absent variability

In the tracing provided:

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

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

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

No recurrent late or prolonged decelerations are present.

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

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

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

Comprehensive and Detailed Explanation From 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:

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 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:

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

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

NCC/AWHONN guidance for tachysystole caused by prostaglandins:

FIRST intervention: Remove the dinoprostone insert.

Reposition the patient (already done).

IV fluid bolus (already done).

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

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

Why other answers are incorrect:

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

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

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

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

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 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 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 Exact Extract NCC-Recommended Sources

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

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

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

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

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

A prolonged deceleration is defined by NICHD and NCC as:

A deceleration lasting ≥2 minutes but <10 minutes

Decrease in FHR of ≥15 bpm

Can occur with or without uterine contractions

This tracing shows:

A deep drop in FHR down to ~60–70 bpm

Duration lasting several minutes

Recovery back to baseline

Moderate variability present afterward

Because variability remains present and the tracing does not show:

Absent variability

Recurrent late decelerations

Recurrent variable decelerations with absent variability

Bradycardia for ≥10 minutes

…it does not meet criteria for Category III.

It is also not bradycardia, because bradycardia requires:

Baseline <110 bpm for 10 minutes or longer

Therefore the correct interpretation is a prolonged deceleration.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Because the fetal myocardium is immature, it has:

Limited ability to increase stroke volume

Limited ability to increase contractility

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

NCC and AWHONN physiology describe:

CO = stroke volume × heart rate

In the fetus, stroke volume is relatively fixed

Therefore, changes in HR directly affect cardiac output

Tachycardia → increases CO

Bradycardia → decreases CO → decreased perfusion and oxygen delivery

Why the other options are incorrect:

A. Activity does not fundamentally determine CO.

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

Correct answer: C. Heart rate