Reports of patients with axillary adenopathy identified on breast imaging after coronavirus disease (COVID-19) vaccination are rising. We propose a pragmatic management approach based on clinical presentation, vaccination delivery, and imaging findings. In the settings of screening mammography, screening MRI, and diagnostic imaging work-up of breast symptoms, with no imaging findings beyond unilateral axillary adenopathy ipsilateral to recent (prior six weeks) vaccination, we report the adenopathy as benign with no further imaging indicated if no nodes are palpable six weeks after the last dose. For patients with palpable axillary adenopathy in the setting of ipsilateral recent vaccination, clinical follow-up of the axilla is recommended. In all these scenarios, axillary ultrasound is recommended if clinical concern persists six weeks after vaccination. In patients with recent breast cancer diagnosis in the pre- or peri-treatment setting, prompt recommended imaging is encouraged as well as vaccination (in the thigh or contralateral arm). Our recommendations align with the ACR BI-RADS Atlas and aim to: 1) reduce patient anxiety, provider burden, and costs of unnecessary evaluation of enlarged nodes in the setting of recent vaccination, and 2) avoid further delays in vaccinations and breast cancer screening during the pandemic.