A nurse is caring for a toddler whose parent states that while bathing the child, she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?

The correct answer is: b.

Choice A: Heart rate 130/min

A heart rate of 130 beats per minute (bpm) is considered high for a 3-year-old child. Normal heart rates for children aged 1-3 years typically range from 80 to 120 bpm. While dehydration can cause tachycardia (increased heart rate), a heart rate of 130 bpm does not necessarily indicate effective rehydration.

Choice B: Urine specific gravity 1.015

Urine specific gravity of 1.015 is within the normal range (1.005–1.030) for a hydrated child. Dehydration increases urine concentration (>1.020), but a normalized value like 1.015 shows that ORT has restored fluid balance. UpToDate and NIH studies (e.g., Binder et al., 2014) highlight urine specific gravity as a precise measure of hydration status, making it the strongest indicator of ORT effectiveness.

Choice C: Respiratory rate 24/min

The normal respiratory rate for a 3-year-old child is between 20 and 30 breaths per minute. A respiratory rate of 24 breaths per minute is within this normal range. While a normal respiratory rate can indicate improved hydration status, it is not the most specific indicator of effective rehydration therapy.

Choice D: Capillary refill less than 3 seconds

Capillary refill time of less than 3 seconds suggests adequate perfusion, as normal is under 2 seconds. Dehydration may prolong this time, but “less than 3 seconds” could include slightly delayed values (e.g., 2.5 seconds). UpToDate and NIH studies (e.g., Doan et al., 2010) note it as useful but less specific than urine specific gravity for confirming ORT effectiveness.

Choice A reason: Headaches are not a specific finding for rhabdomyosarcoma of the nasopharynx, as they can be caused by many other conditions. Headaches may occur if the tumor compresses the cranial nerves or the brain, but this is not a common manifestation.

Choice B reason: Bleeding is not a specific finding for rhabdomyosarcoma of the nasopharynx, as it can be caused by many other conditions. Bleeding may occur if the tumor erodes the blood vessels or the mucosa, but this is not a common manifestation.

Choice C reason: Tearing is not a specific finding for rhabdomyosarcoma of the nasopharynx, as it can be caused by many other conditions. Tearing may occur if the tumor affects the lacrimal duct or the eye, but this is not a common manifestation.

Choice D reason: Swelling is an expected finding for rhabdomyosarcoma of the nasopharynx, as it indicates the presence of a mass in the nasal cavity or the pharynx. Swelling may cause nasal obstruction, difficulty breathing, or facial asymmetry. Swelling may also be palpable or visible on imaging studies.