NCC EFM Certified - Electronic Fetal Monitoring Exam Practice Test

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

This tracing demonstrates a normal, reassuring fetal heart pattern that is technically categorized as Category I, indicating normal fetal acid–base status. Before any decision regarding discharge or induction, NCC emphasizes correct assessment of the tracing quality, fetal status, and uterine activity.

Key Tracing Characteristics

Baseline:Approximately 135–145 bpm, well within the normal range of 110–160 bpm.

Variability:The strip shows moderate variability (6–25 bpm), the strongest indicator of adequate fetal oxygenation per NCC, AWHONN, and NICHD.

Accelerations:Several accelerations are present—another reassuring feature of normal fetal well-being.

Decelerations:No variable, late, or prolonged decelerations are present.

Uterine Activity:The lower channel shows poor recording quality and inconsistent signal—suggesting the toco is not capturing contractions well, not that the patient is contracting excessively or not at all.

Correct interpretation per NCC:

NCC emphasizes distinguishing between physiologic assessment and technical artifact.

The fetal tracing is completely reassuring.

The only abnormality is the poor uterine activity signal, a common triage occurrence due to:

Toco placement

Maternal body habitus

Positioning

Low contraction intensity in early labor

Thus, the correct next step is to optimize equipment (reposition the toco, adjust belt, palpate contractions) and continue to monitor.

Why the other options are incorrect:

B. Admit for induction – NOT indicated

There is no evidence of fetal compromise.

No indication for induction is present (pain score 4/10, reassuring FHR, term pregnancy).

NCC emphasizes avoiding unnecessary interventions.

C. Discharge to home – NOT yet appropriate

You cannot safely discharge a patient with a poorly monitored contraction pattern.

Adequate assessment requires confirming uterine activity—after fixing the toco.

Therefore, the appropriate action is:

A. Adjust tocotransducer and continue to monitor.

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

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

Reflex parasympathetic activation

Decreased FHR (vagal slowing)

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

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

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

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

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

Accurate classification of decelerations requires evaluating their shape, onset, nadir, recovery, relationship to contractions, and variability characteristics. NCC uses the NICHD standardized definitions, reinforced across AWHONN, Miller’s Pocket Guide, Menihan, Simpson, and Creasy & Resnik.

Key features in this tracing:

Abrupt onsetThe FHR drops rapidly from baseline to nadir in less than 30 seconds—this is the defining hallmark of a variable deceleration per NICHD.

Sharp V-shape and deep amplitudeThe tracing shows steep descents and ascents, characteristic of cord compression–type variable decelerations.

Inconsistent timing with contractionsThe decelerations do not begin at the start of contractions (as early decelerations would) and do not consistently begin after the peak of contractions (as late decelerations would). Variable decelerations can occur before, during, or after a contraction—exactly what is demonstrated here.

Rapid return to baselineAnother core feature of variable decelerations in NICHD/NCC definitions.

No uniform contraction relationshipEarly decelerations are symmetrical and mirror contractions. Late decelerations begin after the peak of the contraction. This strip does not match either pattern.

Differentiation per NCC-aligned definitions:

Early Decelerations:Gradual onset (>30 sec), nadir mirrors contraction peak, shallow, uniform.Not present.

Late Decelerations:Gradual descent, nadir after contraction peak, smooth shape.Not present.

Variable Decelerations:Abrupt onset (<30 sec), variable timing, sharp V-shape, rapid recovery, often with shoulders.Exactly matches the tracing.

Therefore, according to NICHD/NCC criteria, the decelerations shown are variable decelerations.

Comprehensive and Detailed Explanation From Exact Extract 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-Aligned Sources:

NICHD definitions:

A variable deceleration is identified by:

Abrupt onset(drop from baseline to nadir in <30 seconds)

Depth ≥15 bpm

Duration ≥15 seconds and <2 minutes

Variable timing relative to contractions

Variable shape (sharp drop, jagged descents, rapid recovery)

The scenario describes:

Abrupt drop from 125 → 80 bpm (rapid onset)

Lasting 90 seconds (still <2 minutes)

Gradual return but still within variable range

Occurring during a contraction

Depth >15 bpm

This meets ALL criteria for a variable deceleration.

Why the other options are wrong:

A. Early deceleration

Requires gradual onset (>30 seconds).

Mirrors contraction shape.

Caused by head compression.

This decel is abrupt, so NOT early.

B. Prolonged deceleration

Requires ≥2 minutes and <10 minutes.

This decel lasts 90 seconds, which is below the threshold.

Correct classification: Variable deceleration.

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 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 Exact Extract Sources:

The tracing demonstrates an abrupt-onset, sharp, V-shaped deceleration, occurring simultaneously with or slightly after a contraction—classic for variable decelerations, which are caused by umbilical cord compression.

According to AWHONN Fetal Heart Monitoring Principles & Practices, variable decelerations are defined by:

“Abrupt decreases in FHR below baseline of at least 15 bpm, lasting at least 15 seconds and less than 2 minutes.”

“Most commonly associated with umbilical cord compression, whether transient or recurrent.”

Physiology reference (Simpson & Miller, Pocket Guide):

Compression of the umbilical vein causes a brief acceleration.

Compression of the umbilical arteries triggers a vagal response, producing a rapid deceleration.

This creates the characteristic sharp ‘V’, ‘U’, or ‘W’ shape on the monitor.

Placental insufficiency (Choice B) produces late decelerations, which are gradual, not abrupt.

Fetal head compression (Choice A) produces early decelerations, which mirror contractions and have a gradual pattern.

Thus, the tracing is most consistent with variable decelerations caused by umbilical cord compression.

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–Based NCC C-EFM References:

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

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

NCC/AWHONN guidance for tachysystole caused by prostaglandins:

FIRST intervention: Remove the dinoprostone insert.

Reposition the patient (already done).

IV fluid bolus (already done).

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

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

Why other answers are incorrect:

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

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

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

Comprehensive and Detailed Explanation From NCC-Aligned 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 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:

NCC/AWHONN emphasize that the primary goal of intrauterine resuscitation is to:

Optimize uteroplacental blood flow, which restores fetal oxygen delivery.

Key measures include:

Maternal repositioning (lateral)

Reducing tachysystole

IV fluid bolus

Correcting maternal hypotension

Stopping oxytocin

Treating underlying causes

Improving maternal oxygenation is supportive, but improving uteroplacental perfusion is the critical first determinant of resuscitation success.

Why the other answers are not first priority:

A. Oxygen — optional and no longer universally recommended unless maternal hypoxemia exists.

B. Minimizing uterine activity — essential, but still secondary to restoring perfusion.

Correct answer: C. Optimizing uteroplacental blood flow

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 NCC-Recommended Sources

The fetal heart rate tracing shows a normal baseline (120–150 bpm), moderate variability, and no decelerations, consistent with a Category I pattern. According to AWHONN’s Fetal Heart Monitoring Principles & Practices and NCC Perinatal Safety recommendations, a Category I tracing reliably indicates normal fetal acid-base status at the time of assessment and is considered reassuring.

Simpson & Creehan emphasize that in triage, management decisions depend on cervical status, contraction pattern, membrane status, and fetal well-being. With a cervix at 1 cm/50%/-2, intact membranes, and no regular labor pattern, she is not in active or latent labor requiring admission, provided fetal status is reassuring.

Menihan states that a normal tracing lasting two hours with moderate variability supports safe discharge when maternal and fetal assessments are normal. Creasy & Resnik confirm that reassuring fetal testing plus absence of labor is appropriate for outpatient management.

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 Exact Extract–Based NCC C-EFM References:

This tracing shows recurrent late decelerations, decreased variability, and subtle baseline shifts—findings that strongly correspond to uteroplacental insufficiency. In trauma cases, NCC emphasizes that placental abruption is the most common fetal complication, caused by shearing forces separating the placenta from the uterine wall.

Key physiologic points per NCC/AWHONN/Menihan:

Maternal blunt abdominal trauma frequently leads to partial or concealed abruption.

Abruption produces decreased uteroplacental blood flow, resulting in:

Late decelerations

Minimal/absent variability

Baseline shifts or instability

Cord accident (option A) typically produces variable decelerations, not late-pattern decelerations.

Fetal trauma (option B) is extremely rare and does not produce a consistent deceleration pattern.

Thus, the physiology most consistent with this tracing and mechanism of injury is placental abruption.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Placental calcifications:

Reduce surface area for maternal–fetal gas exchange

Impair placental perfusion

Are associated with post-dates and chronic insufficiency

Decrease the placenta’s ability to oxygenate the fetus

Why the incorrect answers are wrong:

A. Increased maternal cardiac output → improves uteroplacental perfusion.

B. Open-glottis pushing → improves oxygenation compared with closed-glottis Valsalva pushing.

Correct answer: Placental calcifications.

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

NCC’s Professional Issues domain emphasizes communication, collaboration, and team-based interpretation of electronic fetal monitoring tracings.

For non-emergent differences in interpretation, the first step is:

Discussion and joint review of the tracing by the involved clinicians.

Only if disagreement persists should the chain of command be used. Documentation occurs after consensus or escalation—not as the first step.

Thus, the appropriate first step is C. Have the involved clinicians review the tracing together.

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

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

Effects include:

Increased fetal oxygen consumption

Enhanced fetal cardiac output

Resultant tachycardia, often 160–180 bpm

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

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

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

Thus, the mechanism is increased fetal metabolism.

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

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:

A nonreactive NST with no response to vibroacoustic stimulation indicates:

Possible fetal sleep cycle

Possible CNS depression

Possible hypoxemia

NCC, AWHONN, and MFM guidelines state the next step is a biophysical profile because:

It evaluates fetal tone, movement, breathing, amniotic fluid, and NST

Provides a complete assessment of fetal well-being

Is less invasive and more informative than immediate delivery decisions

Why the wrong answers are incorrect:

B. Cesarean birth — not indicated without confirming fetal compromise.

C. Induction of labor — not indicated until BPP clarifies fetal status.

Correct answer: A. Biophysical profile.

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 Physiologic References:

This strip shows:

Baseline around 150 bpm

Moderate variability

No decelerations

Consistent, strong contractions

A maternal report of severe pain (8/10) and feeling lightheaded

In labor, severe pain + anxiety + hyperventilation commonly cause maternal respiratory alkalosis.

NCC and AWHONN physiology guidance explain:

Hyperventilation → ↓ PaCO₂ → respiratory alkalosis

Symptoms include:

Lightheadedness

Tingling

Dizziness

Sometimes palpitations

This frequently occurs during painful contractions, especially with occiput posterior labor, which is notoriously more painful due to back pressure.

Why other answers are incorrect:

A. Respiratory acidosis occurs with hypoventilation—not present here.

C. Respiratory depression occurs with opioids, magnesium sulfate, or anesthesia—not part of this scenario.

Therefore, the correct answer is B. Alkalosis.

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:

Variability reflects the interplay of the autonomic nervous system—sympathetic and parasympathetic influences—on the fetal myocardium. NCC defines variability as variation in the R–R intervals on the fetal ECG.

Key points:

Variability originates from beat-to-beat fluctuations in ventricular depolarization timing.

These R–R interval changes result from baroreceptor and chemoreceptor responses, vagal modulation, and fetal behavioral states.

Carbon dioxide levels affect chemoreceptors but do not directly define variability.

Thus, variability is best described as resulting from variance in R–R intervals.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Artifact on fetal monitoring:

Appears erratic, disorganized, and without physiologic pattern

Shows random amplitude changes

Often correlates with maternal movement, monitor displacement, or poor signal

Lacks cyclical, repetitive characteristics seen in true dysrhythmias

Fetal dysrhythmias, by contrast:

Have repetitive, patterned, predictable rhythm disturbances

May show uniform premature beats, bigeminy, or sudden rate shifts

Therefore, varied and disorganized = artifact.

Comprehensive and Detailed Explanation From NCC-Aligned Equipment Concepts:

When using external tocodynamometry, uterine contraction intensity cannot be measured in mmHg. It is assessed manually, using palpation. NCC and AWHONN teach:

Contraction intensity is estimated by palpating the fundus during a contraction.

The degree of firmness versus indentation determines intensity:

Mild → uterus easily indented

Moderate → firm, difficult to indent

Strong → rigid, cannot be indented

Why the incorrect answers are wrong:

B. Muscle strength — Not measurable by external or manual exam.

C. Pain — Not a reliable indicator; pain perception varies widely and does not correlate with uterine intensity.

Thus, the correct manual measurement is done through uterine indentation, making A correct.

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 Category II includes:

Minimal variability

Marked variability

Absent accelerations without recurrent decelerations

Indeterminate baseline characteristics

A tracing with no accelerations and no decelerations becomes Category II if paired with marked variability, because marked variability indicates potential stress.

Why other answers are wrong:

A. FHR 110 bpm → normal baseline if variability normal.

B. Sinusoidal pattern → Category III, not Category II.

Correct answer: Marked variability.

Comprehensive and Detailed Explanation From Exact Extract (No URLs):

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

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

• Bradycardia NOT accompanied by absent variability

• Tachycardia

• Minimal variability

• Marked variability

• Absence of accelerations after stimulation

• Recurrent variable decelerations with minimal or moderate variability

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

In this tracing, the fetus demonstrates:

– A prolonged deceleration with subsequent recovery,

– Presence of baseline variability,

– Return toward baseline but not immediately normal.

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

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

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Both fetal tracings (A and B) show:

Baselines around 140–150 bpm

Moderate variability

Intermittent accelerations

No recurrent decelerations

Normal contraction pattern

Overall Category I patterns for both twins

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

There is no evidence of:

Tachysystole

Recurrent variables

Recurrent lates

Prolonged decelerations

Category III patterns

Therefore, the appropriate action is ongoing observation.

Why the incorrect answers are wrong:

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

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

Comprehensive and Detailed Explanation From 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):

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

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

Therefore, palpating for contractions is the required first intervention.

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

NCC and AWHONN explain that Contraction Stress Testing (CST):

Has a higher rate of equivocal (“equivocal–suspicious” or “equivocal–hyperstimulation”) results

Frequently must be repeated or replaced with other tests

Requires inducing contractions, which carries risk (hyperstimulation, preterm labor, uterine rupture in scarred uterus)

NST is used more commonly because it is:

Noninvasive

Easier to perform

Has fewer contraindications

Has a lower rate of equivocal results

Why the others are incorrect:

B — CST does detect fetal compromise reliably and is NOT limited in its reporting structure.

C — A negative CST actually has very high negative predictive value for 7 days, making this answer incorrect.

Thus the correct choice is A. Higher frequency of equivocal results.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The NST strip shows:

Baseline FHR about 140 bpm

Moderate variability

Two or more accelerations meeting 15×15 criteria

No decelerations

Normal, infrequent contractions

Per NCC and AWHONN, a reactive NST is defined as:

≥2 accelerations of 15 bpm × 15 seconds in a 20-minute period

With baseline 110–160 and moderate variability

No recurrent decelerations

A reactive NST at 36 weeks in a hemodynamically stable mother with normal vitals is reassuring, and the appropriate disposition is routine follow-up and discharge.

Why the other options are incorrect:

B. Induce labor – Not indicated solely on maternal age or a reactive NST.

C. Kleihauer-Betke test – Used to quantify fetomaternal hemorrhage after trauma or sensitization risk; there is no such history here.

Therefore, the correct action is A. Discharge home.

Comprehensive and Detailed Explanation From Exact Extract (No URLs or Links):

Early decelerations are defined in NCC and AWHONN resources as gradual, uniform decelerations that mirror uterine contractions and are associated with fetal head compression. AWHONN’s Fetal Heart Monitoring Principles states: “Early decelerations are a benign pattern caused by vagal stimulation secondary to fetal head compression.” Menihan similarly notes: “The mechanism of early decelerations is a vagal reflex response; they do not reflect hypoxia.”

They are periodic, not episodic, because they occur with contractions—which rules out option A.

They typically remain within a normal heart rate range and do not usually fall below 100 bpm; this eliminates option C. NCC Candidate Guide emphasizes that early decelerations are considered a normal physiologic response, not a pathologic pattern, and are categorized as “Category I” when variability is present.

Thus, the correct characteristic is that they are caused by a vagal reflex, making B the correct answer.