Electronic Fetal Heart Monitoring
WEIVER • MFE
EFM
REVIEW Comprehensive Review — FHR Interpretation & Clinical Management
PROMOTING EXCELLENCE IN FETAL MONITORING
MONITORING
Electronic Fetal Heart Monitoring — Comprehensive Review
F H R PAT T E R N S , D E C E L E R AT I O N S , VA R I A B I L I TY, CO N T R A C T I O N S & N U R S I N G I N T E R V E N T I O N S
INSTITUTION NCC — EFM Certification Program EXAM CODE EFM-REVIEW-2026
PROGRAM Electronic Fetal Monitoring Certification ACADEMIC YEAR
EXAM TITLE EFM Comprehensive Review Examination TOTAL QUESTIONS 30 Questions — Comprehensive Review
COURSE TITLE Electronic Fetal Heart Monitoring FORMAT Multiple Choice — Select the Single Best
Answer
REVIEW EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Questions cover EFM strip interpretation, baseline FHR, variability, accelerations, decelerations (early, late, variable, prolonged),
uterine contraction assessment, monitoring methods (external vs. internal), and nursing interventions for nonreassuring
patterns.
▸ Distinguish carefully between deceleration types and their clinical significance, variability categories, and appropriate nursing
interventions.
▸ Correct answers and detailed rationales appear below each question.
SECTION I — FHR INTERPRETATION, DECELERATIONS & CLINICAL Questions 1 –
INTERVENTIONS 30
1. On an EFM strip, what does the TOP half represent and what do the numbers on its vertical axis indicate?
A. Uterine contractions in mm Hg; the bottom half represents FHR
B. The fetal heart rate (FHR) in beats per minute (BPM); the bottom half represents uterine contractions in mm Hg
C. Maternal heart rate in BPM; the bottom half represents FHR
D. Blood pressure readings; the bottom half represents pulse
CORRECT ANSWER B — Top half = FHR (beats per minute, BPM). Bottom half = uterine contractions (mm Hg). Light red
vertical lines = 10 seconds; dark red vertical lines = 1 minute.
RATIONALE EFM strip basics: Top grid = fetal heart rate (vertical axis 30–240 BPM). Bottom grid = uterine activity (vertical
axis 0–100 mm Hg). Paper speed: standard 3 cm/min. Each small square = 10 seconds; each large square (dark
line) = 1 minute. Six large squares = 6 seconds (useful for quick rate calculation: count beats in 6 seconds × 10
= BPM). Understanding strip organization is fundamental to accurate FHR interpretation.
, 2. Baseline fetal heart rate is determined over a minimum of:
A. 5 minutes of tracing
B. 10 minutes of tracing — using any given 2-minute window within that 10-minute segment, excluding accelerations,
decelerations, and periods of marked variability (>25 BPM)
C. 20 minutes of tracing
D. 1 minute of tracing
CORRECT ANSWER B — Baseline is determined over a minimum 10-minute window using any 2-minute segment within
that period. Exclude accelerations, decelerations, and marked variability >25 BPM. Normal baseline:
110–160 BPM.
RATIONALE Baseline FHR classification: Normal = 110–160 BPM. Bradycardia = <110 BPM for >10 min. Tachycardia = >160
BPM for >10 min. The baseline should be rounded to the nearest 5 BPM increment. If the baseline is
indeterminate (unstable), refer to the previous 10-minute window. The baseline represents the mean FHR
when the fetus is not experiencing accelerations, decelerations, or marked variability. It reflects the balance
between sympathetic (↑HR) and parasympathetic (↓HR) input to the sinoatrial node.
3. A fetal heart rate acceleration is defined as an abrupt increase that:
A. Is at least 5 BPM above baseline lasting at least 5 seconds
B. Peaks at ≥15 BPM above baseline, lasts ≥15 seconds (onset to peak <30 seconds) for gestations ≥32 weeks. For <32
weeks: peak ≥10 BPM, duration ≥10 seconds. Accelerations signify fetal well-being
C. Is any increase in heart rate regardless of duration
D. Only occurs during uterine contractions
CORRECT ANSWER B — Acceleration criteria: ≥32 weeks = ≥15 BPM above baseline, ≥15 sec, abrupt onset (<30 sec to
peak). <32 weeks = ≥10 BPM, ≥10 sec. Accelerations are a reliable sign of fetal well-being and predict
absence of metabolic acidemia.
RATIONALE Accelerations represent an intact, responsive fetal autonomic nervous system. They occur spontaneously with
fetal movement or in response to stimuli (contractions, vaginal exam, fetal scalp stimulation, external sounds,
abdominal palpation). The presence of accelerations (spontaneous or provoked) is the most reliable indicator
that the fetus is NOT acidemic at that moment. No nursing intervention is required for accelerations.
Prolonged acceleration = >2 min but <10 min. If ≥10 min = change in baseline. Absence of accelerations alone
does NOT indicate fetal compromise — may represent fetal sleep state (typically 20–40 min cycles).
4. Early decelerations are characterized by which key phrase and what causes them?
A. "Mirrors the contraction" — the deceleration is a symmetrical, gradual decrease with the nadir occurring at the PEAK
of the contraction. Caused by fetal HEAD COMPRESSION. Considered BENIGN/NORMAL
B. "Always bad to be LATE" — nadir occurs after the contraction peak, caused by uteroplacental insufficiency
C. "V-shaped or W-shaped" — abrupt onset, caused by cord compression
D. "Smooth sine wave" — caused by severe fetal anemia
CORRECT ANSWER A — Early decelerations MIRROR the contraction waveform. The nadir (lowest point) occurs at the peak
of the contraction. Caused by fetal head compression → vagal stimulation → transient bradycardia.
NORMAL, no intervention needed.
RATIONALE Early deceleration mechanism: uterine contraction + descent → fetal head compression → increased
intracranial pressure → vagus nerve stimulation (parasympathetic) → transient decrease in FHR. The FHR
returns to baseline as the contraction resolves and head compression is relieved. Common triggers: active
labor, vaginal exams, fundal pressure, membrane rupture. Clinical significance: BENIGN — does NOT indicate
fetal hypoxia. No maternal interventions are required. Often seen in active labor (4–7 cm dilation) and second
stage. Distinguish from late decelerations which appear similar in shape but have different timing (nadir
AFTER contraction peak).
WEIVER • MFE
EFM
REVIEW Comprehensive Review — FHR Interpretation & Clinical Management
PROMOTING EXCELLENCE IN FETAL MONITORING
MONITORING
Electronic Fetal Heart Monitoring — Comprehensive Review
F H R PAT T E R N S , D E C E L E R AT I O N S , VA R I A B I L I TY, CO N T R A C T I O N S & N U R S I N G I N T E R V E N T I O N S
INSTITUTION NCC — EFM Certification Program EXAM CODE EFM-REVIEW-2026
PROGRAM Electronic Fetal Monitoring Certification ACADEMIC YEAR
EXAM TITLE EFM Comprehensive Review Examination TOTAL QUESTIONS 30 Questions — Comprehensive Review
COURSE TITLE Electronic Fetal Heart Monitoring FORMAT Multiple Choice — Select the Single Best
Answer
REVIEW EXAMINATION INSTRUCTIONS
▸ Select the single best answer for each question.
▸ Questions cover EFM strip interpretation, baseline FHR, variability, accelerations, decelerations (early, late, variable, prolonged),
uterine contraction assessment, monitoring methods (external vs. internal), and nursing interventions for nonreassuring
patterns.
▸ Distinguish carefully between deceleration types and their clinical significance, variability categories, and appropriate nursing
interventions.
▸ Correct answers and detailed rationales appear below each question.
SECTION I — FHR INTERPRETATION, DECELERATIONS & CLINICAL Questions 1 –
INTERVENTIONS 30
1. On an EFM strip, what does the TOP half represent and what do the numbers on its vertical axis indicate?
A. Uterine contractions in mm Hg; the bottom half represents FHR
B. The fetal heart rate (FHR) in beats per minute (BPM); the bottom half represents uterine contractions in mm Hg
C. Maternal heart rate in BPM; the bottom half represents FHR
D. Blood pressure readings; the bottom half represents pulse
CORRECT ANSWER B — Top half = FHR (beats per minute, BPM). Bottom half = uterine contractions (mm Hg). Light red
vertical lines = 10 seconds; dark red vertical lines = 1 minute.
RATIONALE EFM strip basics: Top grid = fetal heart rate (vertical axis 30–240 BPM). Bottom grid = uterine activity (vertical
axis 0–100 mm Hg). Paper speed: standard 3 cm/min. Each small square = 10 seconds; each large square (dark
line) = 1 minute. Six large squares = 6 seconds (useful for quick rate calculation: count beats in 6 seconds × 10
= BPM). Understanding strip organization is fundamental to accurate FHR interpretation.
, 2. Baseline fetal heart rate is determined over a minimum of:
A. 5 minutes of tracing
B. 10 minutes of tracing — using any given 2-minute window within that 10-minute segment, excluding accelerations,
decelerations, and periods of marked variability (>25 BPM)
C. 20 minutes of tracing
D. 1 minute of tracing
CORRECT ANSWER B — Baseline is determined over a minimum 10-minute window using any 2-minute segment within
that period. Exclude accelerations, decelerations, and marked variability >25 BPM. Normal baseline:
110–160 BPM.
RATIONALE Baseline FHR classification: Normal = 110–160 BPM. Bradycardia = <110 BPM for >10 min. Tachycardia = >160
BPM for >10 min. The baseline should be rounded to the nearest 5 BPM increment. If the baseline is
indeterminate (unstable), refer to the previous 10-minute window. The baseline represents the mean FHR
when the fetus is not experiencing accelerations, decelerations, or marked variability. It reflects the balance
between sympathetic (↑HR) and parasympathetic (↓HR) input to the sinoatrial node.
3. A fetal heart rate acceleration is defined as an abrupt increase that:
A. Is at least 5 BPM above baseline lasting at least 5 seconds
B. Peaks at ≥15 BPM above baseline, lasts ≥15 seconds (onset to peak <30 seconds) for gestations ≥32 weeks. For <32
weeks: peak ≥10 BPM, duration ≥10 seconds. Accelerations signify fetal well-being
C. Is any increase in heart rate regardless of duration
D. Only occurs during uterine contractions
CORRECT ANSWER B — Acceleration criteria: ≥32 weeks = ≥15 BPM above baseline, ≥15 sec, abrupt onset (<30 sec to
peak). <32 weeks = ≥10 BPM, ≥10 sec. Accelerations are a reliable sign of fetal well-being and predict
absence of metabolic acidemia.
RATIONALE Accelerations represent an intact, responsive fetal autonomic nervous system. They occur spontaneously with
fetal movement or in response to stimuli (contractions, vaginal exam, fetal scalp stimulation, external sounds,
abdominal palpation). The presence of accelerations (spontaneous or provoked) is the most reliable indicator
that the fetus is NOT acidemic at that moment. No nursing intervention is required for accelerations.
Prolonged acceleration = >2 min but <10 min. If ≥10 min = change in baseline. Absence of accelerations alone
does NOT indicate fetal compromise — may represent fetal sleep state (typically 20–40 min cycles).
4. Early decelerations are characterized by which key phrase and what causes them?
A. "Mirrors the contraction" — the deceleration is a symmetrical, gradual decrease with the nadir occurring at the PEAK
of the contraction. Caused by fetal HEAD COMPRESSION. Considered BENIGN/NORMAL
B. "Always bad to be LATE" — nadir occurs after the contraction peak, caused by uteroplacental insufficiency
C. "V-shaped or W-shaped" — abrupt onset, caused by cord compression
D. "Smooth sine wave" — caused by severe fetal anemia
CORRECT ANSWER A — Early decelerations MIRROR the contraction waveform. The nadir (lowest point) occurs at the peak
of the contraction. Caused by fetal head compression → vagal stimulation → transient bradycardia.
NORMAL, no intervention needed.
RATIONALE Early deceleration mechanism: uterine contraction + descent → fetal head compression → increased
intracranial pressure → vagus nerve stimulation (parasympathetic) → transient decrease in FHR. The FHR
returns to baseline as the contraction resolves and head compression is relieved. Common triggers: active
labor, vaginal exams, fundal pressure, membrane rupture. Clinical significance: BENIGN — does NOT indicate
fetal hypoxia. No maternal interventions are required. Often seen in active labor (4–7 cm dilation) and second
stage. Distinguish from late decelerations which appear similar in shape but have different timing (nadir
AFTER contraction peak).
