Summarized Exam Coverage (NCC EFM Certification)
Fetal oxygenation and placental exchange; uterine contraction frequency, duration, intensity, and
resting tone; baseline fetal heart rate (FHR) categories (110–160 bpm); variability (absent,
minimal, moderate, marked); accelerations; deceleration types (early, late, variable, prolonged);
NICHD terminology; category I, II, III tracings; maternal conditions (hypertension, diabetes,
infection); fetal conditions (growth restriction, anemia, hypoxia); intrapartum interventions
(position changes, fluids, oxygen, amnioinfusion, tocolysis); tachysystole management; acid-
base interpretation (cord blood pH, base excess); twin gestation patterns; legal documentation
and communication; emergency algorithms for non-reassuring FHR.
1. A 34-week gestation patient has recurrent variable decelerations to 60 bpm for 45 seconds
each with good return. What is the most appropriate initial intervention?
A) Maternal position change to lateral
B) Immediate cesarean section
C) Increase oxytocin infusion
D) Administer indomethacin
Lateral positioning relieves umbilical cord compression, the primary cause of variable
decelerations.
2. A category III tracing shows absent variability and recurrent late decelerations. Which action
must you take first?
A) Notify the provider and prepare for expedited delivery
B) Document tracing as reassuring
C) Decrease IV fluids
D) Administer oral hydration
Category III requires immediate intrauterine resuscitation and prompt delivery planning due to
risk of fetal acidosis.
3. A fetus at 39 weeks has a baseline of 155 bpm, moderate variability, and early decelerations
with every contraction. This tracing is classified as:
A) Category I
B) Category II
,C) Category III
D) Indeterminate
Early decelerations are benign and reflect head compression; with moderate variability and
normal baseline, the tracing is category I.
4. A patient on oxytocin has a single contraction lasting 140 seconds with a fetal heart rate drop
to 80 bpm for 3 minutes. What is the best next step?
A) Discontinue oxytocin and reposition
B) Increase oxytocin to shorten the contraction
C) Apply fetal scalp electrode
D) Give bolus of terbutaline first
Prolonged deceleration with tachysystole requires stopping oxytocin and relieving uterine
overstimulation; terbutaline is secondary.
5. You observe a fetal heart rate baseline of 125 bpm with minimal variability and no
accelerations for 60 minutes at 41 weeks. The tracing is:
A) Category II
B) Category I
C) Category III
D) Normal
Minimal variability without decelerations or accelerations for >40 minutes is category II –
requires evaluation but not immediate delivery.
6. A mother with chorioamnionitis (temperature 39°C) has a fetal heart rate baseline of 175 bpm.
What is the most likely underlying etiology?
A) Maternal fever causing fetal tachycardia
B) Umbilical cord prolapse
C) Fetal anemia
D) Maternal hypoglycemia
Maternal infection increases fetal metabolic rate and catecholamines, leading to sustained fetal
tachycardia.
7. A variable deceleration has a slow return to baseline after the contraction ends. This suggests:
A) Hypoxemia with myocardial depression
B) Head compression of the vagus nerve
C) Umbilical vein only compression
D) Benign pattern
Slow return to baseline (>30 seconds after contraction end) indicates worsening gas exchange
and impending acidosis.
,8. A fetus at 32 weeks has absent variability without decelerations, but scalp stimulation
produces an acceleration. This finding suggests:
A) Fetal sleep cycle – continue monitoring
B) Severe acidosis
C) Cord prolapse
D) Maternal seizure
Scalp stimulation–induced acceleration indicates a non-acidotic, neurologically responsive
fetus; absent variability may be from immaturity or sleep.
9. Which maternal medication is most likely to cause a sinusoidal fetal heart rate pattern?
A) Nalbuphine (Nubain)
B) Magnesium sulfate
C) Betamethasone
D) Oxytocin
Opioids like nalbuphine can produce a sinusoidal-like pattern; true sinusoidal pattern (fetal
anemia) is rare but opioid effect is exam-relevant.
10. A patient with gestational diabetes has a prolonged deceleration to 70 bpm for 4 minutes.
After repositioning and stopping oxytocin, the FHR remains 80 bpm for 2 more minutes. Next
step?
A) Prepare for immediate delivery (vacuum or cesarean)
B) Give intravenous glucose
C) Wait another 5 minutes
D) Perform amnioinfusion
*Prolonged deceleration >2 minutes despite resuscitation warrants rapid delivery to prevent
hypoxic-ischemic injury.*
11. A term fetus has a baseline of 140 bpm, moderate variability, and a 15×15 acceleration. The
contraction pattern is every 3 minutes. This is:
A) Category I
B) Category II
C) Minimal variability
D) Late deceleration equivalent
Accelerations and moderate variability with normal baseline and no decelerations define a
category I tracing.
12. You are called to a patient with a category II tracing and recurrent late decelerations.
Maternal blood pressure is 90/50 mmHg after epidural. What is the priority?
A) IV fluid bolus and left lateral position
B) Reduce epidural rate
, C) Phenylephrine infusion
D) Discontinue epidural
Epidural-induced hypotension reduces uterine blood flow; fluids and lateral positioning increase
venous return and placental perfusion.
13. A fetus has repeated variable decelerations with “shoulders” on the tracing. This pattern
indicates:
A) Umbilical cord compression without significant hypoxia
B) Placental abruption
C) Fetal acidemia
D) Maternal fever
”Shoulders” (brief acceleration before and after the deceleration) are physiologic compensation
and not a sign of acidosis.
14. A 40-week patient has contractions every 2 minutes, moderate strength, and several late
decelerations. Oxygen 10L is given. After 5 minutes, no change. The next appropriate action is:
A) Notify provider and consider delivery
B) Double oxygen flow rate
C) Apply fetal scalp electrode
D) Decrease IV fluids
Oxygen non-response in late decelerations indicates likely uteroplacental insufficiency requiring
delivery planning.
15. A fetal heart rate baseline is uninterpretable for 10 minutes due to maternal movement and
loss of signal. The best next step is:
A) Apply a fetal scalp electrode
B) Discontinue monitoring
C) Increase ultrasound gain
D) Have the mother perform Valsalva
Scalp electrode provides direct electrical signal, eliminating artifact and lost signal from fetal
movement or maternal obesity.
16. A patient in active labor has a prolonged deceleration. You perform a vaginal exam and feel a
pulsating mass beside the fetal head. What is the diagnosis?
A) Umbilical cord prolapse
B) Placenta previa
C) Head molding
D) Vasa previa
Pulsating cord anterior to the presenting part during a deceleration is cord prolapse until proven
otherwise; elevate presenting part.
Fetal oxygenation and placental exchange; uterine contraction frequency, duration, intensity, and
resting tone; baseline fetal heart rate (FHR) categories (110–160 bpm); variability (absent,
minimal, moderate, marked); accelerations; deceleration types (early, late, variable, prolonged);
NICHD terminology; category I, II, III tracings; maternal conditions (hypertension, diabetes,
infection); fetal conditions (growth restriction, anemia, hypoxia); intrapartum interventions
(position changes, fluids, oxygen, amnioinfusion, tocolysis); tachysystole management; acid-
base interpretation (cord blood pH, base excess); twin gestation patterns; legal documentation
and communication; emergency algorithms for non-reassuring FHR.
1. A 34-week gestation patient has recurrent variable decelerations to 60 bpm for 45 seconds
each with good return. What is the most appropriate initial intervention?
A) Maternal position change to lateral
B) Immediate cesarean section
C) Increase oxytocin infusion
D) Administer indomethacin
Lateral positioning relieves umbilical cord compression, the primary cause of variable
decelerations.
2. A category III tracing shows absent variability and recurrent late decelerations. Which action
must you take first?
A) Notify the provider and prepare for expedited delivery
B) Document tracing as reassuring
C) Decrease IV fluids
D) Administer oral hydration
Category III requires immediate intrauterine resuscitation and prompt delivery planning due to
risk of fetal acidosis.
3. A fetus at 39 weeks has a baseline of 155 bpm, moderate variability, and early decelerations
with every contraction. This tracing is classified as:
A) Category I
B) Category II
,C) Category III
D) Indeterminate
Early decelerations are benign and reflect head compression; with moderate variability and
normal baseline, the tracing is category I.
4. A patient on oxytocin has a single contraction lasting 140 seconds with a fetal heart rate drop
to 80 bpm for 3 minutes. What is the best next step?
A) Discontinue oxytocin and reposition
B) Increase oxytocin to shorten the contraction
C) Apply fetal scalp electrode
D) Give bolus of terbutaline first
Prolonged deceleration with tachysystole requires stopping oxytocin and relieving uterine
overstimulation; terbutaline is secondary.
5. You observe a fetal heart rate baseline of 125 bpm with minimal variability and no
accelerations for 60 minutes at 41 weeks. The tracing is:
A) Category II
B) Category I
C) Category III
D) Normal
Minimal variability without decelerations or accelerations for >40 minutes is category II –
requires evaluation but not immediate delivery.
6. A mother with chorioamnionitis (temperature 39°C) has a fetal heart rate baseline of 175 bpm.
What is the most likely underlying etiology?
A) Maternal fever causing fetal tachycardia
B) Umbilical cord prolapse
C) Fetal anemia
D) Maternal hypoglycemia
Maternal infection increases fetal metabolic rate and catecholamines, leading to sustained fetal
tachycardia.
7. A variable deceleration has a slow return to baseline after the contraction ends. This suggests:
A) Hypoxemia with myocardial depression
B) Head compression of the vagus nerve
C) Umbilical vein only compression
D) Benign pattern
Slow return to baseline (>30 seconds after contraction end) indicates worsening gas exchange
and impending acidosis.
,8. A fetus at 32 weeks has absent variability without decelerations, but scalp stimulation
produces an acceleration. This finding suggests:
A) Fetal sleep cycle – continue monitoring
B) Severe acidosis
C) Cord prolapse
D) Maternal seizure
Scalp stimulation–induced acceleration indicates a non-acidotic, neurologically responsive
fetus; absent variability may be from immaturity or sleep.
9. Which maternal medication is most likely to cause a sinusoidal fetal heart rate pattern?
A) Nalbuphine (Nubain)
B) Magnesium sulfate
C) Betamethasone
D) Oxytocin
Opioids like nalbuphine can produce a sinusoidal-like pattern; true sinusoidal pattern (fetal
anemia) is rare but opioid effect is exam-relevant.
10. A patient with gestational diabetes has a prolonged deceleration to 70 bpm for 4 minutes.
After repositioning and stopping oxytocin, the FHR remains 80 bpm for 2 more minutes. Next
step?
A) Prepare for immediate delivery (vacuum or cesarean)
B) Give intravenous glucose
C) Wait another 5 minutes
D) Perform amnioinfusion
*Prolonged deceleration >2 minutes despite resuscitation warrants rapid delivery to prevent
hypoxic-ischemic injury.*
11. A term fetus has a baseline of 140 bpm, moderate variability, and a 15×15 acceleration. The
contraction pattern is every 3 minutes. This is:
A) Category I
B) Category II
C) Minimal variability
D) Late deceleration equivalent
Accelerations and moderate variability with normal baseline and no decelerations define a
category I tracing.
12. You are called to a patient with a category II tracing and recurrent late decelerations.
Maternal blood pressure is 90/50 mmHg after epidural. What is the priority?
A) IV fluid bolus and left lateral position
B) Reduce epidural rate
, C) Phenylephrine infusion
D) Discontinue epidural
Epidural-induced hypotension reduces uterine blood flow; fluids and lateral positioning increase
venous return and placental perfusion.
13. A fetus has repeated variable decelerations with “shoulders” on the tracing. This pattern
indicates:
A) Umbilical cord compression without significant hypoxia
B) Placental abruption
C) Fetal acidemia
D) Maternal fever
”Shoulders” (brief acceleration before and after the deceleration) are physiologic compensation
and not a sign of acidosis.
14. A 40-week patient has contractions every 2 minutes, moderate strength, and several late
decelerations. Oxygen 10L is given. After 5 minutes, no change. The next appropriate action is:
A) Notify provider and consider delivery
B) Double oxygen flow rate
C) Apply fetal scalp electrode
D) Decrease IV fluids
Oxygen non-response in late decelerations indicates likely uteroplacental insufficiency requiring
delivery planning.
15. A fetal heart rate baseline is uninterpretable for 10 minutes due to maternal movement and
loss of signal. The best next step is:
A) Apply a fetal scalp electrode
B) Discontinue monitoring
C) Increase ultrasound gain
D) Have the mother perform Valsalva
Scalp electrode provides direct electrical signal, eliminating artifact and lost signal from fetal
movement or maternal obesity.
16. A patient in active labor has a prolonged deceleration. You perform a vaginal exam and feel a
pulsating mass beside the fetal head. What is the diagnosis?
A) Umbilical cord prolapse
B) Placenta previa
C) Head molding
D) Vasa previa
Pulsating cord anterior to the presenting part during a deceleration is cord prolapse until proven
otherwise; elevate presenting part.
