The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms tumor. The nurse is developing a plan of care for the child and suggests including which of the following in the plan of care?
1. Monitor the temperature for hypothermia.
2. Monitor the blood pressure for hypotension.
3. Inspect the urine for the presence of hematuria at each voiding.
4. Palpate the abdomen for an increase in the size of the tumor every 8 hours.
3
Rationale: If Wilms tumor is suspected, the tumor mass should not be palpated. Excessive ma-nipulation can cause seeding of the tumor and cause spread of the cancerous cells. Fever (not hypothermia), hematuria, and hypertension (not hypotension) are clinical manifestations associ-ated with Wilms tumor.
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