Free NCC EFM Practice Exam with Questions & Answers

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

NCC physiology content specifically includes maternal autoimmune influences on fetal cardiac conduction. Conditions such as maternal lupus (SLE) or Sjogren’s syndrome may produce anti-Ro/SSA and anti-La/SSB antibodies. These antibodies cross the placenta and damage fetal conduction tissue.

The primary site of injury is the fetal atrioventricular (AV) node, leading to:

First-, second-, or complete third-degree heart block

A slow, regular ventricular rate typically 50–70 bpm

Loss of beat-to-beat variability because ventricular myocardium does not display normal autonomic modulation

This mechanism is extensively described in AWHONN, NCC physiology materials, and maternal–fetal physiology texts.

Option A: Antibodies do not target fetal RBCs; that describes hemolytic disease of the newborn.

Option B: Targeting maternal WBCs is not fetal-specific.

The correct affected structure is the fetal AV node.

Therefore, the correct answer is C. The fetal atrioventricular node.

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

NCC emphasizes that only objective acid-base assessment can diagnose intrapartum asphyxia. This is accomplished with cord arterial blood gas analysis showing:

pH < 7.0–7.1

Base deficit ≥ 12 mmol/L

Elevated PCO₂

FHR patterns suggest risk, but do not diagnose asphyxia.

Apgar scores, especially at 1 minute, do not correlate reliably with acidemia.

Thus, cord gas analysis is the correct determinant.

Comprehensive and Detailed Explanation From Exact Extract Without Links:

According to the NCC C-EFM Content Outline and AWHONN Fetal Heart Monitoring Principles, recurrent decelerations are specifically defined as decelerations that occur with ≥50% of uterine contractions in a 20–30-minute window, but standardized interpretation guidelines used by NCC and ACOG categorize recurrent patterns based on any 30-minute evaluation period.

AWHONN (FHM 6th Ed.) explains that fetal heart patterns must be evaluated over “a sufficiently long segment, typically 30 minutes, to determine whether the pattern is intermittent or recurrent.”

Menihan & Simpson further emphasize that recurrent decelerations imply a persistent physiologic stressor, requiring systematic evaluation and intrauterine resuscitation. NCC's Candidate Guide ties this rule directly into categorization within Category II and III tracings. Therefore, 30 minutes is the correct standard evaluation interval for determining recurrence.

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

AWHONN and Menihan emphasize that most fetal dysrhythmias detected intrapartum are premature atrial contractions (PACs)—the most common benign rhythm variation. They typically appear as intermittent, irregular deflections on the fetal heart rate tracing without affecting variability or baseline.

Miller’s Pocket Guide to Fetal Monitoring states that PACs are usually transient, self-limiting, and require only observation unless accompanied by tachyarrhythmia or hemodynamic compromise. When variability is preserved and no repetitive pattern or sustained tachycardia occurs, no intrauterine resuscitation measures are indicated.

Simpson and Creehan describe that oxygen administration and fluid boluses are not recommended for benign dysrhythmias, as they do not improve fetal conduction patterns and may contribute to unnecessary interventions.

The NCC 2025 Candidate Guide specifies that correct management requires distinguishing benign arrhythmias from pathologic tachyarrhythmias, which would require escalation. In the absence of fetal compromise or maternal pathology, the appropriate action is continued observation.

Therefore, the correct management is to continue to observe.

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:

Tachysystole = >5 contractions in 10 minutes averaged over 30 minutes (NICHD).

However, NCC and AWHONN intervention guidelines state:

If tachysystole appears in one or two consecutive 10-minute segments, especially with Category II or III patterns, intervention must begin immediately.

Intervention includes:

Stopping/reducing oxytocin

Maternal repositioning

IV bolus

Tocolysis if needed

Why the wrong answers are wrong:

A. Waiting 30 minutes delays necessary fetal resuscitation.

C. Stage of labor does not determine when to intervene.

Correct answer: B. If tachysystole is seen for one or two 10-minute segments

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 (NCC-Referenced Sources)

AWHONN and Menihan clearly state that classification of decelerations is determined by their timing relative to uterine contractions:

Early decelerations: “mirror the contraction; onset, nadir, and recovery occur simultaneously with the contraction.”

Late decelerations: “begin after the contraction begins and return to baseline after the contraction ends.”

Depth is not a differentiating feature, as both early and late decelerations may vary in depth. The onset-to-nadir interval is used to differentiate variable vs. early/late, not early vs. late.

Thus, timing relative to contractions is the correct NCC-supported answer.

Comprehensive and Detailed Explanation From Exact Extract–Based NCC C-EFM References (No URLs):

Interpretation of fetal heart rate (FHR) tracings in the NCC C-EFM exam follows the standardized NICHD three-tier classification, which is fully adopted in NCC’s content outline and recommended references such as AWHONN Fetal Heart Monitoring Principles & Practices, Miller’s EFM Pocket Guide, Menihan, Simpson’s Perinatal Nursing, and Creasy & Resnik.

Baseline:

The tracing demonstrates an FHR baseline around 145–150 bpm, which falls within the normal range of 110–160 bpm. NCC references define baseline as the mean FHR rounded to increments of 5 bpm over a 10-minute window.

Variability:

The strip shows minimal variability, with amplitude fluctuations approximately 0–2 bpm.

According to NCC-aligned definitions:

Moderate variability: 6–25 bpm

Minimal variability: 1–5 bpm

Absent variability: undetectable amplitude

This tracing shows minimal variability, not moderate, so it cannot be Category I.

Accelerations:

No accelerations are present. Lack of accelerations alone does not classify the tracing as Category III.

Decelerations:

There are no recurrent late decelerations, no recurrent variable decelerations, and no prolonged decelerations. Without these, and with minimal variability, the tracing does not meet Category III criteria.

Category III criteria (per NICHD/NCC):

Must include at least one of the following:

Absent variability with recurrent late decelerations

Absent variability with recurrent variable decelerations

Absent variability with bradycardia

Sinusoidal pattern

None of these are present.

Category II criteria (per NICHD/NCC):

Category II includes tracings that are not Category I or III.

Examples specifically listed include:

Minimal variability

Absent accelerations after fetal stimulation

Tachycardia

Bradycardia without absent variability

Variable or late decelerations occurring intermittently

Because this tracing shows minimal variability, a normal baseline, no accelerations, and no recurrent decelerations, it fits squarely into Category II.

Therefore, the correct classification is Category II.

Comprehensive and Detailed Explanation From 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.