C-EFM Electronic fetal monitoring
certification emphasizing interpretation
skills, fetal assessment, and obstetric
patient safety.
Question 1
A 28-year-old woman at 39 weeks gestation is in active labor. The fetal heart rate
(FHR) tracing shows a baseline of 145 bpm with moderate variability.
Contractions are every 3 minutes, lasting 60 seconds. The most important
determinant of fetal oxygenation during labor is:
A) Maternal blood pressure
B) Uterine blood flow and placental perfusion
C) Fetal hemoglobin concentration
D) Maternal oxygen saturation
Rationale: Fetal oxygenation during labor depends primarily on adequate uterine
blood flow and placental perfusion, which deliver oxygenated blood from the
maternal circulation to the fetus. Uterine contractions can temporarily decrease
placental perfusion, making this the critical factor in fetal oxygen delivery. While
maternal blood pressure, fetal hemoglobin, and maternal oxygen saturation are
important, uterine blood flow is the most direct determinant of fetal oxygenation.
Question 2
A patient at 41 weeks gestation is being induced with oxytocin. The FHR tracing
shows a baseline of 130 bpm with moderate variability and recurrent late
decelerations. These decelerations are most likely caused by:
A) Head compression
B) Umbilical cord compression
C) Uteroplacental insufficiency
D) Fetal sleep state
,Rationale: Late decelerations are caused by uteroplacental insufficiency, resulting
in transient fetal hypoxemia during uterine contractions. They typically begin at
the peak of the contraction and return to baseline after the contraction ends. Head
compression causes early decelerations, umbilical cord compression causes
variable decelerations, and fetal sleep state does not cause decelerations.
Question 3
A 32-year-old woman at 38 weeks gestation is in labor. The FHR baseline is 150
bpm, and the tracing shows moderate variability. The nurse notes that the fetal pH
obtained from a scalp sample is 7.28. This finding is best interpreted as:
A) Normal fetal acid-base status
B) Fetal respiratory acidosis
C) Fetal metabolic acidosis
D) Pre-terminal acidosis
Rationale: A normal fetal scalp pH is 7.25–7.35. A pH of 7.28 is within normal
limits and indicates adequate fetal oxygenation and acid-base balance. A pH < 7.20
is concerning for fetal acidosis and may indicate the need for intervention. Fetal
scalp pH sampling is an adjunctive method to assess fetal well-being when the
FHR tracing is non-reassuring.
Question 4
A 25-year-old woman at 40 weeks gestation is in labor. The FHR tracing shows a
baseline of 140 bpm with moderate variability. The patient has been pushing for 2
hours. Which of the following FHR changes would be most concerning for
worsening fetal acid-base status?
A) Progressive decrease in baseline variability to minimal
B) Transient accelerations with pushing
C) Decelerations that return to baseline quickly
D) Baseline tachycardia of 160 bpm
Rationale: Progressive loss of baseline variability, particularly from moderate to
minimal or absent, is concerning for fetal acidemia and hypoxia. The NICHD
classification defines moderate variability as 6–25 bpm, minimal as ≤5 bpm.
,Absent or minimal variability in the presence of recurrent decelerations is
concerning for metabolic acidemia.
Question 5
A 30-year-old woman at 37 weeks gestation is in early labor. The FHR tracing
shows a baseline of 135 bpm with moderate variability and occasional early
decelerations. Early decelerations are most consistent with:
A) Fetal head compression
B) Umbilical cord compression
C) Uteroplacental insufficiency
D) Fetal hypoxia
Rationale: Early decelerations are caused by fetal head compression during
uterine contractions, leading to vagal stimulation and a slowing of the FHR that
mirrors the contraction. They are generally benign and not associated with fetal
hypoxia or acidemia. The deceleration begins with the contraction and returns to
baseline as the contraction ends.
Question 6
A 34-year-old woman at 39 weeks gestation with gestational diabetes is in labor.
The FHR tracing shows a baseline of 155 bpm with moderate variability and
recurrent variable decelerations. Variable decelerations are most commonly caused
by:
A) Umbilical cord compression
B) Head compression
C) Placental abruption
D) Maternal hypotension
Rationale: Variable decelerations are caused by umbilical cord compression,
which leads to vagal stimulation and transient decreases in FHR. The characteristic
shape of variable decelerations—abrupt onset and recovery with variable depth and
duration—reflects intermittent cord compression. Head compression causes early
decelerations, and placental abruption or maternal hypotension can cause late
decelerations.
, Question 7
A 27-year-old primigravida at 41 weeks gestation is in active labor. The FHR
tracing shows a baseline of 145 bpm with moderate variability and recurrent late
decelerations. The most appropriate initial intervention is:
A) Change maternal position and assess for uterine hyperstimulation
B) Prepare for immediate cesarean delivery
C) Administer oxygen at 10 L/min via non-rebreather mask
D) Increase the oxytocin infusion rate
Rationale: The first step in managing recurrent late decelerations is to improve
uteroplacental perfusion by changing maternal position (lateral position) and
assessing for uterine hyperstimulation. If oxytocin is infusing, it should be reduced
or discontinued. Oxygen and other interventions may follow, but position change is
the priority.
Question 8
A 29-year-old woman at 38 weeks gestation is in labor. The FHR tracing shows a
baseline of 150 bpm, moderate variability, and accelerations with fetal movement.
This tracing is best classified as:
A) Category I (normal)
B) Category II (indeterminate)
C) Category III (abnormal)
D) Non-reassuring
Rationale: A Category I tracing includes a baseline of 110–160 bpm, moderate
variability, and the presence of accelerations with no late or variable decelerations.
This tracing is normal and predictive of normal fetal acid-base status at the time of
observation. No intervention is required.
Question 9
A 31-year-old woman at 40 weeks gestation is in active labor. The FHR tracing
shows a baseline of 120 bpm with minimal variability and recurrent late
decelerations. This tracing is best classified as:
A) Category I (normal)
B) Category II (indeterminate)
certification emphasizing interpretation
skills, fetal assessment, and obstetric
patient safety.
Question 1
A 28-year-old woman at 39 weeks gestation is in active labor. The fetal heart rate
(FHR) tracing shows a baseline of 145 bpm with moderate variability.
Contractions are every 3 minutes, lasting 60 seconds. The most important
determinant of fetal oxygenation during labor is:
A) Maternal blood pressure
B) Uterine blood flow and placental perfusion
C) Fetal hemoglobin concentration
D) Maternal oxygen saturation
Rationale: Fetal oxygenation during labor depends primarily on adequate uterine
blood flow and placental perfusion, which deliver oxygenated blood from the
maternal circulation to the fetus. Uterine contractions can temporarily decrease
placental perfusion, making this the critical factor in fetal oxygen delivery. While
maternal blood pressure, fetal hemoglobin, and maternal oxygen saturation are
important, uterine blood flow is the most direct determinant of fetal oxygenation.
Question 2
A patient at 41 weeks gestation is being induced with oxytocin. The FHR tracing
shows a baseline of 130 bpm with moderate variability and recurrent late
decelerations. These decelerations are most likely caused by:
A) Head compression
B) Umbilical cord compression
C) Uteroplacental insufficiency
D) Fetal sleep state
,Rationale: Late decelerations are caused by uteroplacental insufficiency, resulting
in transient fetal hypoxemia during uterine contractions. They typically begin at
the peak of the contraction and return to baseline after the contraction ends. Head
compression causes early decelerations, umbilical cord compression causes
variable decelerations, and fetal sleep state does not cause decelerations.
Question 3
A 32-year-old woman at 38 weeks gestation is in labor. The FHR baseline is 150
bpm, and the tracing shows moderate variability. The nurse notes that the fetal pH
obtained from a scalp sample is 7.28. This finding is best interpreted as:
A) Normal fetal acid-base status
B) Fetal respiratory acidosis
C) Fetal metabolic acidosis
D) Pre-terminal acidosis
Rationale: A normal fetal scalp pH is 7.25–7.35. A pH of 7.28 is within normal
limits and indicates adequate fetal oxygenation and acid-base balance. A pH < 7.20
is concerning for fetal acidosis and may indicate the need for intervention. Fetal
scalp pH sampling is an adjunctive method to assess fetal well-being when the
FHR tracing is non-reassuring.
Question 4
A 25-year-old woman at 40 weeks gestation is in labor. The FHR tracing shows a
baseline of 140 bpm with moderate variability. The patient has been pushing for 2
hours. Which of the following FHR changes would be most concerning for
worsening fetal acid-base status?
A) Progressive decrease in baseline variability to minimal
B) Transient accelerations with pushing
C) Decelerations that return to baseline quickly
D) Baseline tachycardia of 160 bpm
Rationale: Progressive loss of baseline variability, particularly from moderate to
minimal or absent, is concerning for fetal acidemia and hypoxia. The NICHD
classification defines moderate variability as 6–25 bpm, minimal as ≤5 bpm.
,Absent or minimal variability in the presence of recurrent decelerations is
concerning for metabolic acidemia.
Question 5
A 30-year-old woman at 37 weeks gestation is in early labor. The FHR tracing
shows a baseline of 135 bpm with moderate variability and occasional early
decelerations. Early decelerations are most consistent with:
A) Fetal head compression
B) Umbilical cord compression
C) Uteroplacental insufficiency
D) Fetal hypoxia
Rationale: Early decelerations are caused by fetal head compression during
uterine contractions, leading to vagal stimulation and a slowing of the FHR that
mirrors the contraction. They are generally benign and not associated with fetal
hypoxia or acidemia. The deceleration begins with the contraction and returns to
baseline as the contraction ends.
Question 6
A 34-year-old woman at 39 weeks gestation with gestational diabetes is in labor.
The FHR tracing shows a baseline of 155 bpm with moderate variability and
recurrent variable decelerations. Variable decelerations are most commonly caused
by:
A) Umbilical cord compression
B) Head compression
C) Placental abruption
D) Maternal hypotension
Rationale: Variable decelerations are caused by umbilical cord compression,
which leads to vagal stimulation and transient decreases in FHR. The characteristic
shape of variable decelerations—abrupt onset and recovery with variable depth and
duration—reflects intermittent cord compression. Head compression causes early
decelerations, and placental abruption or maternal hypotension can cause late
decelerations.
, Question 7
A 27-year-old primigravida at 41 weeks gestation is in active labor. The FHR
tracing shows a baseline of 145 bpm with moderate variability and recurrent late
decelerations. The most appropriate initial intervention is:
A) Change maternal position and assess for uterine hyperstimulation
B) Prepare for immediate cesarean delivery
C) Administer oxygen at 10 L/min via non-rebreather mask
D) Increase the oxytocin infusion rate
Rationale: The first step in managing recurrent late decelerations is to improve
uteroplacental perfusion by changing maternal position (lateral position) and
assessing for uterine hyperstimulation. If oxytocin is infusing, it should be reduced
or discontinued. Oxygen and other interventions may follow, but position change is
the priority.
Question 8
A 29-year-old woman at 38 weeks gestation is in labor. The FHR tracing shows a
baseline of 150 bpm, moderate variability, and accelerations with fetal movement.
This tracing is best classified as:
A) Category I (normal)
B) Category II (indeterminate)
C) Category III (abnormal)
D) Non-reassuring
Rationale: A Category I tracing includes a baseline of 110–160 bpm, moderate
variability, and the presence of accelerations with no late or variable decelerations.
This tracing is normal and predictive of normal fetal acid-base status at the time of
observation. No intervention is required.
Question 9
A 31-year-old woman at 40 weeks gestation is in active labor. The FHR tracing
shows a baseline of 120 bpm with minimal variability and recurrent late
decelerations. This tracing is best classified as:
A) Category I (normal)
B) Category II (indeterminate)
