Free NCC EFM Practice Exam with Questions & Answers | Set: 2

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The strip shows abrupt, deep variable decelerations, which are highly suspicious for cord compression.

Following rupture of membranes, the FIRST step recommended by NCC/AWHONN is:

Immediate vaginal examination to rule out cord prolapse.

Cord prolapse requires emergent action, and examination must occur before repositioning or fluids.

Why the other answers are incorrect:

C. Left lateral positioning is appropriate after ruling out cord prolapse.

A. IV fluids do not address the potentially life-threatening cause.

Correct first action is: vaginal examination.

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 Exact Extract–Based NCC C-EFM References:

NCC and AWHONN standards state that the fetal heart tones are most clearly heard when the Doppler probe is placed over the fetal back, because:

The fetal heart transmits sound most directly through the fetal spine.

Amniotic fluid and fetal position allow the strongest conduction at the back.

During Leopold maneuvers, identification of the back guides optimal placement.

Placing the Doppler over the abdomen or chest does not provide the strongest or most reliable fetal signal.

Therefore, the correct placement is over the fetal back.

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–Based NCC C-EFM References:

NCC C-EFM uses NICHD terminology to describe key FHR characteristics: baseline, variability, accelerations, and decelerations. In this strip, the following findings are present:

Baseline:The baseline appears approximately 135–145 bpm, which is within the normal 110–160 bpm range described in NCC and AWHONN materials.

Variability:Beat-to-beat fluctuation is within 6–25 bpm, which meets the definition of moderate variability. NCC and NICHD define moderate variability as amplitude range of 6–25 bpm; this is associated with adequate fetal oxygenation and a normal fetal acid–base status.

Accelerations:The tracing shows distinct increases in FHR above the baseline by at least 15 bpm lasting 15 seconds or more but less than 2 minutes. NCC and NICHD define an acceleration in a term fetus precisely as “a visually apparent abrupt increase in FHR, with peak ≥15 bpm above baseline, lasting ≥15 seconds and <2 minutes.” The pattern shown fits this definition clearly.

Category determination:A tracing with normal baseline, moderate variability, and accelerations without decelerations is classified as Category I, not Category II. Category II is reserved for tracings that are not clearly Category I or III, such as minimal or marked variability, recurrent variables, or prolonged decelerations.

Marked variability consideration:Marked variability is defined as amplitude >25 bpm. While the tracing is somewhat jagged, the fluctuation does not sustain >25 bpm amplitude over a 10-minute segment and instead remains in the moderate range, so it does not meet criteria for marked variability.

Given these observations, the most accurate description of the tracing from the options provided is that it demonstrates accelerations.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

Normal umbilical arterial values per NCC/AWHONN/Menihan:

pH: 7.20–7.30

PaCO₂: 45–55 mmHg

HCO₃: 20–24 mEq/L

Base deficit: 0 to –5 (normal to mild respiratory changes)

This sample shows:

pH 7.25 → normal

Base deficit –4 → no metabolic acidosis

HCO₃ normal

Slightly elevated PaCO₂, consistent with mild respiratory influence but still normal

PaO₂ 20 mmHg is normal for cord arterial blood

This profile is not acidotic (acidosis requires pH <7.10 and base deficit ≥12).

It also does not indicate hypoxia, which would present with metabolic acidosis.

Therefore: Normal.

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:

This tracing demonstrates:

A sudden prolonged deceleration following epidural placement

Minimal variability during the deceleration

Event occurring within 15 minutes of epidural

NCC, AWHONN, and Menihan emphasize that maternal hypotension is the most common complication immediately following epidural analgesia. Hypotension leads to:

Reduced uteroplacental perfusion

Fetal bradycardia or prolonged decelerations

Decreased variability during the deceleration

Typical fetal response to maternal hypotension:

Late-like or prolonged deceleration with weakening variability, exactly like the strip shown.

Therefore, the FIRST and most critical step is to check maternal blood pressure.

Other options:

B. Continue to monitor — unsafe when a prolonged deceleration is present.

C. Cervical exam — not indicated; the fetal tracing deterioration is temporally linked to epidural placement.

Thus, the correct action is A. Check maternal blood pressure.

Comprehensive and Detailed Explanation From NCC-Aligned Sources:

The black tracing (Baby A) demonstrates:

Baseline ~170–175 bpm

Moderate variability

No recurrent decelerations

This is fetal tachycardia.

NCC physiology guidelines list common causes of fetal tachycardia:

Maternal fever / infection (chorioamnionitis)

Maternal dehydration

Maternal anxiety

Maternal hyperthyroidism

Fetal infection

Certain medications (terbutaline, illicit stimulants)

Why the other options are incorrect:

A. Fetal positioning does not influence baseline heart rate.

C. Magnesium sulfate typically lowers fetal baseline and variability—it does not cause tachycardia.

Thus, the most likely etiology is infection.

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