NCC EFM Exam Breakdown & Study Guide with correct answers

NCC EFM Exam Breakdown & Study Guide Content on exam - correct answer -Pattern recognition & intervention: 70% -Physiology: 11% -Fetal assessment methods: 9% -EFM equipment: 5% -Professional issues: 5% Pattern recognition & intervention - correct answer -FHR baseline -FHR variability -FHR accelerations -FHR decelerations -Normal uterine activity -Abnormal uterine activity -Fetal dysrhythmias -Maternal complications -Uteroplacental complications -Fetal complications FHR Descriptors - correct answer 1) Baseline 2) Variability 3) Presence of accels 4) Presence of decels 5) Changes in trends overtime FHR Baseline - correct answer Average FHR rounded to nearest 5 during a 10 min window -110 to 160 -excludes accels, decels, & marked variability -must have 2 mins to identify as a baseline (doesn't need to be continuous) Fetal Bradycardia - correct answer 110 for ≥10 min -Causes: hypotension (ex: after epi), cord prolapse, head compression, congenital defect, rapid descent, abruption or rupture, tachysystole, post dates, hypoglycemia, lupus (heart block) -With ↓ O2, blood will be shunted to brain, heart, & adrenals, eventually ↓ FHR to ↓ O2 demands of heart muscle -Verify not mom's HR, vaginal exam (r/o prolapse), resuscitate, evaluate arrhythmia, expedite delivery Fetal Tachycardia - correct answer 160 for ≥10 min -Causes: fetal anemia, maternal fever or infection, fetal immaturity (preterm), SVT, maternal anxiety (catecholamines), dehydration, hyperthyroid, hypoxia -Med causes: terbutaline, catecholamines (epinephrine, norepi) -Assess mom's temp & infection risk (GBS, PROM) FHR Variability - correct answer Irregular in amplitude & frequency, quantified by peak to trough -Caused by sympathetic vs parasympathetic, r/t neuro maturity -Less in preterm due to undeveloped CNS -Absent: undetectable, flat -Minimal: ≤5 bpm but detectable -Moderate: 6-25 bpm -Marked: 25 bpm (indeterminate baseline), significance unknown Minimal variability - correct answer ≤5 bpm but detectable Sleep, sedated, or sick -Sleep cycle: 20-60 mins -Sedated: CNS depressant (ex: mag), 1-2 hrs -Sick (acidemia): unresolved w intervention -Priority: maximize oxygenation (position, bolus, O2 if needed) Moderate variability - correct answer 6 to 25 bpm -Reliably predicts the absence of metabolic acidosis (even w decels) FHR Accelerations - correct answer Reliably predicts absence of metabolic acidemia (spontaneous or stimulated) -Onset to peak in 30 sec -For ≥32 wks: 15x15 (peak ≥15 bpm above baseline lasting ≥15 sec) -For 32 wks: 10x10 -Prolonged accel: 2-9 mins (at 10 becomes change of baseline) Early deceleration - correct answer Nadir aligns w contraction peak, gradual onset (≥30 secs to nadir), benign vagal response 1) Pressure on fetal head 2) Increased intracranial pressure 3) Alteration in cerebral blood flow 4) Central vagal stimulation 5) FHR deceleration Periodic vs Episodic - correct answer Periodic: caused by contractions -recurrent: occurs w ≥50% of contractions in 20 min -intermittent: w 50% of contractions in 20 mins Episodic: spontaneous Variable deceleration - correct answer Caused by cord compression -Interventions: position change, amnioinfusion -Abrupt onset: 30 seconds from onset to nadir dropping ≥15 bpm lasting 15 secs to 2min -Transient rise in PCO2 & fall in PO2 Mechanisms of variable decelerations - correct answer Abruptness r/t pressure changes 1) Vein obstruction → reflex tachy -↓ venous return & cardiac output → hypotens → baroreceptor reflex ↑ in FHR to maintain BP 2) Arterial obstruction → decreased FHR -obstructed blood flow back to placenta → HTN → baroreceptor reflex of slowing FHR to maintain BP Late decelerations - correct answer Uteroplacental insufficiency -Indicative of transient fetal hypoxemia -Gradual onset: ≥30 secs to nadir w nadir occurring after peak of contraction -Priority is to maximize uteroplacental blood flow: position lateral (off vena cava & aorta), fluid bolus (perfusion), O2, avoid tachysystole Mechanisms of a late deceleration - correct answer Low O2 → chemoreceptor response peripheral vasoconstriction → blood flow to vital organs → HTN → baroreceptor vagal stimulation → FHR decel 1) Decreased uteroplacental oxygenation (transient hypoxemia) 2) Chemoreceptor stimulation 3) Alpha adrenergic response (catecholamines, peripheral vasoconstriction) 4) Fetal HTN 5) Baroreceptor stimulation 6) Parasympathetic response 7) FHR deceleration 8) ↓ myocardial stress Prolonged deceleration - correct answer Decrease of ≥15 bpm lasting 2 to 9 mins (≥10 = change of baseline) -Vagal stimulation -Causes: hypotension, maternal hypoxia, cord prolapse, rapid decent, profound cord compression, uterine rupture Sinusoidal pattern - correct answer Visually apparent, smooth, sine wave-like pattern in FHR lasting ≥20 minutes -oscillation frequency: 3-5 cycles/min -no variability classification or reactivity -r/t severe anemia: previa, hemorrhage, abruption, RH isoimmunization, asphyxia, infection, cardiac anomaly, twin to twin transfusion, gastroschesis -Transient if 20min, can be r/t thumb sucking or opioids (stadol, fentanyl) Interventions - correct answer -Position change: off of vena cava & aorta, least invasive, 1st line of treatment -Fluid bolus -Amnioinfusion (for variables) -Tocolytics (terb) -Ephedrine to ↑ BP -Supplemental O2: not used w O2 95%, can cause vasoconstriction, free radical formation, ocular toxicity if used limit to 15-30min Category I tracing - correct answer Normal acid base balance -Baseline between 110 to 160 -Moderate variability -No late, variable, or prolonged decels -May have early decels -May or may not have accels Category II tracing - correct answer Indeterminate acid base balance -Minimal variability -Marked variability -Late or variable decels -Bradycardia with variability -Tachycardia -Prolonged decels -Absent variability w NO decels -Absence of induced acccel WITH fetal stimulation Category III tracing - correct answer Predictive of abnormal acid base balance at that moment -Sinusoidal rhythm: has to last ≥20min, r/t anemia (previa, bleeding, abruption) -Absent variability WITH one of the following: bradycardia, recurrent late or recurrent variable decels -Decide for c/s within 30min Normal uterine activity - correct answer ≤5 contractions in 10 mins averaging over 30 min window -adequate contractions: q2-3 lasting 80-90s -intensity: 25-75 mmhg -resting tone: 10-15 mmhg -MVU: 200-220 in 10 mins -intercontraction interval (relaxation time) should be 45-60sec Tachysystole - correct answer 5 contractions in 10 mins averaged over 30 min window -tetanic contractions: 90 secs -position change -500 LR to dilute uterotonic -↓ pitocin (see protocol) -tocolytic (terbutaline) -O2 if decel Tachysystole & pitocin - correct answer With fetal tolerance -If not resolved in 15min, ↓ pit by 1/2 -If not resolved in another 15min, pause pit -If pit's off for 30 min, resume pit at 1/2 of current dose -If off for 30 min, start @ initial order dose With fetal intolerance: pit off immediately Hypertonous labor - correct answer Frequent & painful but poor quality contractions occurring in latent labor -despite increased tone, not enough pressure to cause cx change -indicative of CPD or malpresentation -tx: comfort care, pitocin, AROM Hypotonic labor - correct answer Weak & insufficient labor occurring during the active phase -inadequate, infrequent, & less intense contractions don't dilate or efface cx -caused by tired uterus or overdistention (poly, multiple gestation, LGA) Arrest of labor - correct answer 6cm dilated w/ ROM & one of the following w no cx change: -4 hrs of adequate contractions (200 MVUs) -6 hrs of inadequate contractions Fetal dysrhythmias - correct answer 1) SVT: 210-300 bpm -tx w digoxin (↑ dose to cross placenta) -concern w hydrops, CHF (heart stress), ↑ O2 demand & use, ↓ stroke volume, demise 2) Congenital heart block (60 bpm): 3rd degree → concern w hydrops, lupus, CHF 3) Ectopic beats: extra beats heard, benign, may be transient Lupus (SLE) - correct answer Can cause congenital 3rd degree heart block -bradycardia -autoimmune → inflammatory response → overgrowth of collagen in heart muscle -damages fetal conduction system of the heart, attacks fetal tissue -usually diagnosed in 2nd trimester Preterm labor - correct answer Cx dilation bw 20-36.6 wks -late preterm: 34-36.6 wks -common risk factors: multiples, previous PTD (greatest), uterine or cx abnormalities, infection, 18 months bw pregnancies, IUGR -↓ reserve & ↓ parasympathetic maturity -↑ baseline, ↓ variability, ↑ variable decels Treatment for preterm labor - correct answer 1) Steroids (BMZ, DMZ): allows for synthesis of surfactant & ↓ intracranial hemorrhage risk -most beneficial after 48 hrs, effects last 1-2 wks, can give 2nd round after 2 wks -↑ FHR, ↓ variability & accels -↑ blood sugar & fluid retention 2) Terbutaline (betamimetic): delays PTD by 2-3 days to give steroids -SE: hyperglycemia, hypotension, tachycardia -Not given w ↑HR, bleeding, uncontrolled diabetes 3) Nifedipine / procardia (Ca channel blocker): ↓ contractility of smooth muscles, vasodilates 4) Indocin (NSAID, prostaglandin inhibitor): tocolytic -AE: oligo, GI upset, renal failture, PP hemorrhage 5) Mag: neuroprotection, vasodilates ↑ blood flow to brain, ↓ risk of CP -can cause fetal bradycardia & ↓ variability Postdates pregnancy - correct answer 42 wks -risk of oligo, ↓ placental perfusion, & meconium aspiration -newborn appearance: peeling dry wrinkled skin, long nails, thinner (weight loss) -↑ rate of c/s, recommended to induce at 41 wks -↑ late decels (old placenta) & variables (oligo) Hypertension (HTN) - correct answer BP 140/90 -tx w Ca channel blockers, thiazides, BB -avoid ACE inhibitors & ARBs (congenital defect) 1) Chronic: present prior to pregnancy -risk of superimposed preeclampsia, abruption, stroke (endothelial damage to vessels), stress on L ventricle (to overcome pressure) 2) Gestational: begins after 20 wks, returns to normal PP (no proteinuria: 300mg/0.3 pcr) -↑ BP is sustained 6 hrs apart -risk of poor perfusion, SGA Preeclampsia & HELLP - correct answer ↑BP & proteinuria or a s/s: poor implantation of arterioles & trophoblasts cause ↓ blood flow to placenta, ↑ BP to compensate -mild: 140/90, protein 300mg/24hr or 1-2g dipstick -severe: 160/110, protein 5g/24hr or 3g dipstick, N/V, HA, hyperreflexia, clonus -prevent w baby ASA in 1st trimester (vasodilate) -damages kidneys, liver, heart, lungs, blood cells & vessels, neuro (cerebral edema), optic nerve -AE: oligo, IUGR, pulmonary edema, HA, epigastric pain, blurry vision, abruption, IUFD, seizure, liver rupture, renal failure, DIC, CVA -can cause eclampsia (seizure) from cerebral ischemia & edema, may abrupt or rapidly dilate -HELLP: hemolysis, ↑ liver enzymes (AST, ALT), ↓ platelets (100k) Treatment of preeclampsia & HTN - correct answer -Induce by 39 wks 1) Mag: muscle relaxant used to prevent seizure -loading dose 4-6g/hr, maintenance 2-4g/hr -therapeutic lvl: 4-8 mEq/L -↓ FHR variability, hypotonia, resp depression -antidote: calcium gluconate 1g/10ml D5W -SE: NV, flushing, HA, ↓ reflexes, pulmonary edema, hypotension, resp depression, oliguria 2) BB: don't use w asthma or ↓ HR, caution w diabetes (masks hypoglycemia) 3) Hydralazine: relaxes smooth muscles -can cause rebound tachycardia 4) Ca channel blocker (procardia, nifedipine): relaxes smooth muscles, ↑ renal perfusion & urinary output 5) Valium or keppra w eclampsia Diabetes - correct answer -Excess glucose delays surfactant production (RDS) -T1 & T2 more likely to cause congenital abnormalities (heart & neural tube defect) -Hypoglycemia at birth: glucose crosses placenta but not insulin, fetus has ↑ insulin production & bottoms out after delivery -Risk of LGA, fetal acidosis, impaired perfusion, polycythemia, demise, UTI, polyhydramnios, abruption, PPH, Pre-E (r/t vascular damage), miscarriage -Induce at 38-39 wks Types of diabetes - correct answer 1) T1: insulin dependent (don't secrete insulin) 2) T2: insulin resistant 3) Gestational: placenta acts as antagonist to insulin, demand for production ↑ 2-3x -resolves w placental expulsion Infection - correct answer 1) GBS: bacteria normally found in the vagina & rectum, typically harmless but can pass to fetus during delivery -can cause meningitis, pneumonia, or sepsis -screened from 36-38 wks, tx w antibiotics during labor if positive 2) Chorioamnionitis: infection of membranes, can cause PTD, requires antibiotic tx (risk w PROM) 3) HepB: give infant hepB vax & HBIG 4) HIV: infant will need antivirals, no breastfeed 5) TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes): commonly associated w congenital abnormalities -other: syphillis, varicella zoster, parvovirus B19 Maternal obesity - correct answer -Risk of diabetes, preeclampsia, DVT, infection, PPH (↑ estrogen), miscarriage -Fetus: NTD, heart defect, macrosomia (4000g, 8-13), PTD -Recommended weight gain: 11-20 lbs (compared to 25-35 in average weight) Uteroplacental complications - correct answer 1) Previa: total = covering cx os, marginal = 2cm of os, low lying = 2-3.5 cm from os (usually resolves) -painless bright red bleeding -risk: AMA, uterine scarring, fibroids, smoking, multiples -pelvic rest, bedrest, rhogam (rh-), steroids, PTD 2) Abruption: placental separation from uterus -painful bleeding (may be concealed), ↑ frequency ↓ amplitude contractions, ↑ fundal height, rigid abd 3) Uterine rupture: risk w overdistended uterus or previous surgery (poly, LGA, TOLAC, pit) -abrupt pain, fetal intolerance, no contractions, hematuria, head unengaged (loss of station), chest or shoulder pain (blood accumulation in peritoneum) Fetal injury & hypoxia - correct answer 1) Cerebral palsy: motor disorder caused by brain damage before or during birth -Infection → meningitis → brain damage (TORCH, chorioamnionitis, GBS) -Vacuum or forceps assisted delivery -Poor perfusion of O2 (abruption, rupture, cord abnormality, HIE, asphyxia) 2) Subgaleal hematoma: brain bleed & IICP caused by external head trauma (vacuum or forceps) 3) HIE: hypoxic ischemic encephalopathy -causes: cord compression, placental insufficiency, smoking, abruption, rupture, shoulder dystocia, anemia -can cause IUGR, CP, epilepsy, cognitive impairment, organ damage Physiology - correct answer -Uteroplacental circulation -Fetal circulation -Fetal HR regulation -Factors affecting fetal oxygenation Uteroplacental circulation - correct answer (R arrow indicates blood flow) -Uterine artery → spiral arterioles → intervillous space → diffusion to chorionic villi → oxygenated blood & nutrients to umbilical vein → fetal circulation -Opposite occurs to rid deoxygenated blood & waste from uterine artery -Trophoblasts allow diffusion from chorionic villi & intervillous space without mom & baby RBCs mixing Fetal circulation - correct answer -Umbilical vein → bypass liver through ductus venosus → inferior & superior vena cava → R atrium -Ductus venosus has most highly oxygenated blood -R atrium → L atrium via foramen ovale to bypass lungs → L ventricle → aorta -Ductus arteriosus connects pulmonary artery to aorta to further bypass lungs -Alveoli are filled with fluid shunting blood away from lungs -In utero, R side has higher pressure keeping the foramen ovale open, w cord clamp this shifts to L side -Iliac arteries → umbillical arteries → deoxygenated blood out Fetal HR regulation - correct answer Controlled by the sinoatrial (SA) node -Rate is affected by maturity of parasympathetic nervous system (cholinergic, beta cell relaxation of smooth muscles) -Variability: sympathetic (alpha) vs parasympathetic (beta) -Baroreceptors influence FHR in response to BP changes (↑ BP causes ↓ FHR) -Chemoreceptors respond to hypoxia & ↑ CO2 w tachycardia & HTN Factors affecting fetal oxygenation - correct answer -Uterine activity: contractions ↓ blood flow, causes stasis in intervillous space -Maternal factors: AMA, poor nutrition, BMI 18 or 30, CHF, anemia, HTN, diabetes, infection -Anesthesia: ↓ BP -Drugs: cocaine & nicotine vasoconstricts, nicotine causes CO to cross placenta (↓ ability of Hgb to carry O2) marijuana ↑ CO2 lvls -Placental factors: calcifications (post dates, smoking, clotting d/o, diabetes, HTN), previa, abruption -Umbilical blood flow: cord compression, umbilical abnormalities (single artery), prolapse Maternal factors affecting fetal oxygenation - correct answer 1) ↓ maternal O2: respiratory distress, hypoventilation, seizures, trauma, smoking 2) ↓ maternal O2 carrying capacity: anemia, carboxihemoglobin (smoking, poisoning, drugs) 3) ↓ uterine blood flow: hypovolemia, hypotension, anesthesia, dorsal or lithotomy positioning 4) chronic maternal conditions: vasculopathy (lupus, diabetes, HTN), antiphospholipid Uteroplacental factors affecting fetal oxygenation - correct answer 1) tachysystole 2) placental abruption 3) uteroplacental dysfunction 4) placental infarction 5) chorioamnionitis 6) abnormalities (fibroids, septum) 7) abnormal implantation of placenta (previa) or cord (valementous, marginal, vasa previa) Fetal assessment methods - correct answer -Auscultation -Fetal movement & stimulation -Non stress test (NST) -Biophysical profile (BPP) -Cord blood & acid base balance Auscultation - correct answer Intermittently listening to fetal heart sounds w fetoscope or doppler to assess FHR -Detects baseline, rhythm, increases & decreases from baseline -Cannot determine variability or classify decels -Use of fetoscope can verify presence of arrhythmia (most accurate) & clarifies halving or doubling -Listen to FHR before, during, & for 30 sec after contraction -Feel for mom's radial pulse to differentiate Fetal movement & stimulation - correct answer -Kick count: 10 movements in 2 hrs (starting at 28 wks) -To ↑ movement, have ice chips (auditory stimulation) or juice (sugar) -Do not do scalp stim when FHR is not at baseline (don't use during a decel) Non stress test (NST) - correct answer Can be done 26 wks -Reactive: 2 accels in 20 mins (can prolong to 40min) with moderate variability -Acoustic stim: ≤3, 1 min apart lasting 3 sec each (not used for oligo or 32 wks), elicits startle reflex -Valid for 24 hrs Biophysical Profile (BPP) - correct answer Normal = 2 points, abnormal = 0 -Can be done ≥28 wks, valid for 7 days -BPP done over 30 mins 1) Fetal heart rate 2) Breathing movements 3) Gross body movements 4) Muscle tone: extension/flexion 5) Amniotic fluid volume: (2cm or AFI 5) Scoring a BPP - correct answer Will get 2 points for each of the following: -Reactive NST: 2 accles in 20min -Breathing: 1 lasting 60 secs or 2 lasting 30 secs -Gross movements: 3 of arms, legs, or body -Tone: 1 flexion & extension of arms, legs, hands -AFI: either a 2cm pocket or a total of 5cm (normal 5-25cm) Interpretation of BPP - correct answer -8 to 10 = reassuring (unless oligo) -6 = equivocal, repeat in 24 hrs (if pt is term then delivery is recommended) -4 = further testing needed Normal ABGs - correct answer -pH ≥7.1 -CO2 60 -Bicarb 22 -pO2 20 -BD 12 -BE: -12 Cord blood & acid base balance - correct answer Direct measurement of oxygenation (at the time of delivery) -Base deficit or base excess of +/-12 & a pH 7.1 = high probability of neonatal encephalopathy r/t intrapartum -Umbilical artery value is more predictive -Respiratory acidosis: ↑ CO2 60, normal BD/BE, normal bicarb, can develop quickly & be resolved easily -Metabolic acidosis: normal CO2, ↓ bicarb 22, abnormal BD/BE, r/t anaerobic metabolism (lactic acid build up), difficult to resolve -CAN have both metabolic & respiratory (↑ CO2, ↓ bicarb, abnormal BD/BE) Imbalance definitions - correct answer 1) Hypoxia: ↓ O2 in tissue 2) Hypoxemia: ↓ O2 in blood 3) Acidosis: ↑ H+ in tissue 4) Acidemia: ↑ H+ in blood 5) Asphyxia: hypoxia w metabolic acidosis (causes organ damage) EFM Equipment - correct answer -External EFM -Internal EFM (ISE & IUPC) -Artifact -Signal ambiguity -Failure & troubleshooting Use of EFM - correct answer Tells us whether fetus is oxygenated (indirect measurement) -Does not ↓ rates of infant mortality or CP -Poor at recognizing deoxygenation but reliable at predicting normal pH -Low risk: q30 in active stage, q15 in 2nd stage -High risk: q15 in active stage, q5 in 2nd stage External FHR monitor - correct answer -Non invasive, records baseline, variability, & patterns -Provides permanent record -Can be intermittent or continuous -May restrict maternal movement -Signal may be affected by maternal position, obesity, fetal position & movement, poly -Troubleshooting: reposition EFM or mom, apply gel, confirm fetal position -Most commonly mistaken for mom w breech (near aorta) External tocodynamometer - correct answer Detects changes in shape of the abdomen resulting from uterine tension -place pressure sensor over the fundus at point of maximum intensity -only monitors frequency & duration (does not monitor intensity) -use in conjunction w palpation Internal fetal scalp electrode (ISE) - correct answer -Directly monitors fetal ECG -Indicated when continuous FHR is unable to be achieved with external EFM -Requires ROM & dilation (2cm) -Direct conduit for infection (pierces skin) -Contraindications: previa, herpes, HIV, hepatitis (may use w GBS but not recommended) -Avoid sutures, face, fontanelle, genitalia (can trace on buttocks) -Will pick up maternal HR w demise -May halve FHR 200 Intrauterine pressure catheter (IUPC) - correct answer A catheter that measures uterine pressure during labor -measures intensity of contractions & resting tone -requires ROM & dilation -can be used for amnioinfusion -insert to 35-45 cm mark -troubleshooting: verify position (check markings, have pt cough), flush catheter, recalibrate -risks: placental or uterine perforation, infection Artifact - correct answer Interference in recording or transmission, seen as vertical lines along tracing -Causes: vaginal exam, fetal movement, connection issue, hair or caput w ISE -R/o arrhythmia (can see & hear skips, has baseline, isolated spikes), try another method of monitoring, verify w fetoscope Signal ambiguity - correct answer EFM picking up maternal HR (or another fetus) -Verify whether maternal HR or FHR w use of pulse ox monitor, ISE, or fetoscope -Can appear as accels with pushing Professional issues - correct answer -Legal -Ethics -Patient safety -Quality improvement Legal - correct answer -Informed consent: procedure risks, benefits, & alternate methods explained -Consent is implied in emergencies -Consent may be revoked at any time -Negligence: breech of duty (standard of care not met) directly causing damages • failure to recognize, failure to take action, failure to document, incorrect procedure -Malpractice: an act or a failure to act that causes injury or harm (professional negligence, must have a license to commit) Ethics - correct answer Moral principles that govern behavior, ideals, & standards -Autonomy: allow pt to make decisions -Veracity: tell the truth -Fidelity: commitment -Justice: equal & fair tx -Beneficence: duty to do good -Nonmaleficence: duty to do no harm -Confidentiality & privacy Patient safety - correct answer Sentinel event: patient safety event causing injury or death -one of the leading causes is poor communication -SBAR to improve communication Quality improvement - correct answer Actions that lead to measurable improvement outcomes in pt care areas -Standard of care: how qualified providers should act to prevent injury or harm -EBP: best available practices based on research, guidelines, & expertise -Validity: accuracy -Reliability: consistency