A 25-year-old female tells you her water broke. On examination you observe a greenish amniotic fluid and the neonate's head crowning. Immediately after delivery, the male neonate is crying, has cyanotic hands and feet, and is moving all extremities. What is your first action?

• A. Dry and stimulate him.
• B. Suction his right nostril.
• C. Suction his left nostril.
• D. Suction his mouth.

Answer: (A)

The main idea being tested is how to manage a newborn who is vigorous at birth, even when meconium-stained fluid is involved. In a healthy, term infant who is crying, moving, and has good muscle tone, the first step after delivery is to dry the baby and provide gentle stimulation to promote breathing and warmth. This immediate care helps prevent hypothermia and supports the already-present respiratory effort.

Although the fluid is meconium-stained, the infant’s crying and active movements indicate adequate spontaneous respiration and tone. Suctioning the mouth or nose is not routinely required in a vigorous newborn; it’s reserved for babies with secretions obstructing the airway or with poor breathing or tone. Since this baby is crying and moving well, performing dry and stimulation first is the best initial action. Acrocyanosis (cyanosis of the hands and feet) is common in newborns and typically not a sign of distress when the baby is otherwise vigorous.

If the infant had been limp, not crying, or not breathing well, the next steps would involve clearing the airway if needed and beginning resuscitation with supportive ventilation. But in this scenario, starting with drying and stimulating is the appropriate first action.