What is the next step in managing a newborn with good muscle tone, tachycardia, and mild cyanosis in the distal extremities, who is crying after delivery at 39 weeks gestation?

Immediate Management: Routine Care with Skin-to-Skin Contact

The next step is to dry and stimulate the infant with a towel and place on the mother's chest for routine skin-to-skin care (Option B). 1

Rationale Based on Assessment Criteria

This newborn meets all three criteria for routine care according to the 2015 American Heart Association Neonatal Resuscitation Guidelines 1:

• Term gestation? Yes (39 weeks) 1
• Good tone? Yes (documented good muscle tone) 1
• Breathing or crying? Yes (noted to be crying) 1

When all three answers are "yes," the infant may stay with the mother for routine care rather than being moved to a radiant warmer for resuscitation interventions 1.

Understanding the Mild Acrocyanosis

The mild cyanosis in the distal extremities (acrocyanosis) is a normal finding in the immediate newborn period and does not require intervention 2:

• Newborns normally have oxygen saturation levels in the 70-80% range for several minutes after birth, which can result in the appearance of cyanosis during this transitional period 2
• Blood oxygen levels in uncompromised newborns generally do not reach extrauterine values until approximately 10 minutes after birth 2
• Peripheral cyanosis (acrocyanosis) in the hands and feet is common and benign, distinct from central cyanosis which would involve the trunk and mucous membranes 2, 3

Appropriate Routine Care Protocol

The correct management includes 1:

• Drying the infant to prevent hypothermia and provide tactile stimulation 1
• Placing skin-to-skin with the mother on her chest 1
• Covering with dry linen to maintain normal temperature 1
• Ongoing observation of breathing, activity, and color 1

Why Other Options Are Incorrect

Option A (Bag-valve mask ventilation) is inappropriate because 1:

• This infant is breathing and crying, indicating adequate spontaneous respirations 1
• Positive pressure ventilation is only indicated for infants with apnea, gasping, or labored breathing with heart rate <100/min 1

Option C (Immediate cord clamping) is contraindicated because 1:

• Infants who are breathing and crying may undergo delayed cord clamping 1
• Immediate clamping is only recommended for infants who are NOT breathing or crying, so resuscitation can commence promptly 1

Option D (Infant warmer with blow-by oxygen) is unnecessary because 1, 2:

• The infant does not meet criteria for moving to a radiant warmer (all three assessment questions were "yes") 1
• Supplemental oxygen should only be provided if central cyanosis persists beyond 5-10 minutes of life 2, 3
• Peripheral cyanosis alone does not warrant oxygen therapy 2

Critical Monitoring During Skin-to-Skin Care

While providing routine care, staff must ensure 1:

• Continuous observation by trained staff members with frequent vital sign recording 1
• Safe positioning with the infant's face visible, head in "sniffing" position, nose and mouth uncovered, and neck straight 1
• Assessment of breathing, activity, color, tone, and position to avert positions that obstruct breathing 1
• The mother remains awake and alert; when she wants to sleep, the infant should be placed in a bassinet 1

Common Pitfall to Avoid

Do not rely on visual assessment of cyanosis alone 2, 3. While this infant's acrocyanosis is normal, if there were concerns about central cyanosis or oxygenation, pulse oximetry with neonatal-specific probes should be used, as clinical assessment of skin color is a poor indicator of oxygenation status 2, 3. However, in this scenario with a crying, vigorous term infant, such monitoring is not immediately indicated 1.