EFM EFM - Electronic Fetal Monitoring Documentation and Communication Questions and Answers 2 — Questions and Answers
Question 1: A nurse documents 'late decelerations noted, physician notified at 0320, no new orders received.' What is the NEXT most appropriate action?
- Activate the chain of command by notifying the charge nurse or supervisor (Correct answer)
- Wait 30 minutes and re-notify the physician
- Discontinue EFM and switch to intermittent auscultation
- Document that the situation resolved spontaneously
Correct answer: Activate the chain of command by notifying the charge nurse or supervisor
When a provider fails to respond adequately to a reported concern, the nurse must escalate through the chain of command to protect patient safety.
Question 2: Which element is MOST critical to include when documenting a scalp stimulation test in the medical record?
- Fetal heart rate response (acceleration present or absent) (Correct answer)
- The nurse's name and credentials only
- The maternal blood pressure at the time of the test
- Whether the patient consented verbally
Correct answer: Fetal heart rate response (acceleration present or absent)
The clinical value of scalp stimulation documentation lies in recording whether an acceleration occurred, as this indicates fetal acid-base status.
Question 3: In EFM documentation, what does the term 'recurrent' decelerations mean?
- Occurring with ≥50% of uterine contractions in any 20-minute window (Correct answer)
- Occurring at least once per hour
- Occurring three or more times in a row
- Occurring only during the second stage of labor
Correct answer: Occurring with ≥50% of uterine contractions in any 20-minute window
NICHD defines recurrent decelerations as those occurring with 50% or more of uterine contractions within any 20-minute period.
Question 4: What is the recommended approach when a portion of the EFM strip is unreadable due to artifact?
- Document the artifact, describe maternal and fetal status at the time, and note corrective measures taken (Correct answer)
- Discard that portion of the strip and note it was uninformative
- Restart the monitor without any documentation
- Mark the strip as Category I to avoid liability
Correct answer: Document the artifact, describe maternal and fetal status at the time, and note corrective measures taken
Thorough documentation of artifact, clinical status, and corrective actions taken maintains the integrity of the medical record and demonstrates professional nursing judgment.
Question 5: When using closed-loop communication during a fetal emergency, the person receiving an order should:
- Repeat the order back aloud and receive confirmation before executing (Correct answer)
- Silently confirm and proceed immediately without feedback
- Write the order down and verify after the emergency
- Delegate confirmation to the charge nurse
Correct answer: Repeat the order back aloud and receive confirmation before executing
Closed-loop communication requires the receiver to verbally repeat back the order so the sender can confirm accuracy before the action is taken.
Question 6: How long must EFM paper strips be retained per standard US hospital accreditation requirements?
- As part of the permanent medical record per state law, typically 7–10 years or longer (Correct answer)
- Only until the patient is discharged
- For a minimum of 30 days post-delivery
- Until the infant reaches age 18, in all states
Correct answer: As part of the permanent medical record per state law, typically 7–10 years or longer
EFM strips are part of the legal medical record and must be retained according to state law, commonly 7–10 years, though some states require retention until the child's majority.
EFM EFM - Electronic Fetal Monitoring Documentation and Communication Questions and Answers 2
A nurse documents 'late decelerations noted, physician notified at 0320, no new orders received.' What is the NEXT most appropriate action?